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Graduate Student Journal of Psychology                                                                            Copyright 2008 by the Department of Counseling & Clinical Psychology

2008, Vol. 10                                                                                                                        Teachers College, Columbia University                         ISSN 1088-4661

Starving to Win:

An Exploration of Eating Disorders in Female Athletes

Sarah J. Bernstein
Teachers College, Columbia University

Although viewed as paragons of fitness and health, many female athletes struggle with eating

disorders. Athletes participating in sports that emphasize aesthetics or a thin-build, such as gym-

nastics, figure skating, and endurance running, are at particular risk for the development of eat-

ing disorders. While Anorexia Nervosa and Bulimia Nervosa affect an athlete’s emotional and

psychological well-being, they also cause permanent damage to physical health. The Female

Athlete Triad refers to the three-fold condition of disordered eating, amenorrhea, and osteoporo-

sis that commonly occurs in physically active girls and women. This paper examines the etiology

of disordered eating in female athletes, explores the influence of coaches on eating disorder de-

velopment, and introduces potential complications in treatment.

With the 1988 Olympic Games rapidly approaching,

15-year-old U.S. gymnast Christy Henrich’s dream of win-

ning an Olympic gold medal was in clear sight. However,

when a national judge recommended she lose weight, the

4’10, 90-pound Henrich began a routine of unhealthy eat-

ing practices. She developed both Anorexia Nervosa and

Bulimia Nervosa, struggling for seven years before finally

dying of multiple organ failure at age 22. At the time of

death, Henrich weighed a minuscule 47 pounds. Although

horrific, Henrich’s battle with an eating disorder was not

uncommon in the gymnastics community. As her mother

recalled, “The first thing other athletes told her was if

there’s something you want to eat, eat it and throw it up.

That’s the first thing you learn when you’re on the U.S.

national team” (Ryan, 1995, p. 57).

Society views female athletes, particularly those com-

peting at the elite level, as the quintessential models of fit-

ness and health. Yet as cases like the death of Christy Hen-

rich suggest, these athletes may not be as healthy as they

appear. According to a U.S. Olympics study of 215 elite

female athletes from 18 different sports, more than half of

the athletes fasted, restricted fluid intake, took laxatives

and/or diuretics, and engaged in efforts to increase sweat-

ing by wearing plastic suits and using saunas. Moreover,

the majority of the female athletes reported intense pressure

to lose weight from coaches, fellow teammates, parents,

and the media (Franseen & McCann, 1996). Thus, despite

the appearance of hale physical conditions, many athletes

struggle with eating disturbances. There is a strong rela-

tionship between female athletes and eating disorders;

studies show that 15-62% of female adult athletes display

weight control behaviors (Nativ, 1994). Rates of eating

disorders  among female athletes  have also risen  over the

Correspondence to Sarah Bernstein at sjb2136@columbia.edu.

last 10-15 years  (Berg, 2000).  In a study of eating-

disordered women who were hospitalized, Davis and Ken-

nedy (1994) found that 60% of the patients had been in-

volved in competitive athletics or dance prior to the onset

of their disorder. The results of these studies are sobering,

indicating the need for a closer inspection into the connec-

tion between athletes and discrepant eating patterns. In the

case of eating disorders, who is at risk? Are some athletes

more susceptible to eating disturbances than others?  This

paper will examine possible risk factors, health concerns,

and eating-related identification issues in the female athlete

population as well as explore potential treatment options.

Types of Eating Disorders

The term ‘Eating Disorder’ encompasses a wide range

of disturbances in eating patterns. Ninety percent of those

with eating disorders are female (Thompson & Sherman,

1993). Due to the relatively lower prevalence of eating dis-

orders in males, this paper will restrict its focus to the psy-

chopathology of eating disorders in females. The major

types of eating disorders are Anorexia Nervosa (AN), Bu-

limia Nervosa (BN), and Eating Disorder, Not Otherwise

Specified (Eating Disorder, NOS). The latter category de-

scribes individuals who have an eating problem but do not

fit the diagnostic criteria for AN or BN (Kalodner, 2005).

The DSM-IV-TR (American Psychiatric Association,

2000) defines four specific criteria for AN. The first is that

the individual refuses to maintain a normal body weight,

and often weighs 15% below what is expected for her age

and height. Even though the individual may be drastically

underweight, she has an intense fear of gaining weight and

becoming “fat,” and experiences disturbances in the way

she views her body (e.g., an emaciated individual may re-

port feeling overweight). The individual is in denial of the

seriousness of her low body weight condition and has an



EATING DISORDERS IN FEMALE ATHLETES

65

absence of at least three consecutive menstrual cycles, a

medical condition known as amenorrhea (American Psy-

chological Association, 2000). A female can also be diag-

nosed with amenorrhea if her periods occur only when in-

duced by estrogen hormones (Wilson & Walsh, 1991).

Other medical signs and symptoms of AN include hair and

nail loss, lanugo (the appearance of fine hair on the face

and arms), muscle weakness, gastrointestinal problems,

cardiac arrhythmia, hypotension, hypothermia, and dehy-

dration and electrolyte deficiencies. Anorexia has a mortal-

ity rate that ranges from 1-18% each year (Thompson &

Sherman, 1993).

Unlike individuals with AN who practice restrictive

eating or starving, individuals with BN recurrently vacillate

between episodes of binge eating and compensatory purg-

ing behavior. During a binging episode an individual suf-

fering from BN consumes a large amount of food over a

small period of time, experiencing a major loss of control

over eating. To prevent weight gain she then engages in

subsequent purging behaviors, which may take the form of

self-induced vomiting, strict dieting/fasting, excessive ex-

ercise, or laxative and/or diuretic use. To be diagnosed with

BN, the DSM-IV-TR requires a minimum average of two

binge eating/purging episodes per week for at least three

months (American Psychological Association, 2000). Some

signs and symptoms of BN are menstrual irregularities,

dental/gum disease, electrolyte imbalance, swollen parotid

glands, gastrointestinal problems, dehydration, and light-

headedness and dizziness (Thompson & Sherman, 1993).

As with AN, an individual with BN has a persistent con-

cern about her body shape and weight, which may in turn

affect self-evaluation (Wilson & Walsh, 1991).

Etiological and Psychosocial Factors of Eating Disorders

in Female Athletes

Although twin studies have demonstrated that eating

disorders have a strong genetic component (Bulik, Sullivan,

& Wade, 2000), they are linked to certain psychosocial

factors as well. Some of these social factors include, but are

not limited to, family attitudes around eating, peer influ-

ences, and unrealistic media images of thin women (Polivy

& Herman, 2002). According to social learning theory,

people view others as tools to model their own behavior,

with the individual and her environment influencing each

other. This was supported by Cash and Fleming (2002),

who found that peers shape one another’s body image in

significant ways. Thompson and Sherman (1993) coined

the term contagion effect to describe how dangerous eating

behaviors are often spread through a peer or social group.

Applying the framework of social learning to eating disor-

ders and female athletes, studies illustrate how the culture

of an athletic team affects subsequent eating behaviors

among its members.

Burckes-Miller and Black (1991) observed that peers

from athletic teams may exert a more powerful influence

on body image than peers from other social settings. The

researchers attributed this finding to shared team values

often promoted within the athletic environment. For exam-

ple, in high-endurance sports such as long distance running,

many athletes and coaches believe that the thinner the run-

ner, the faster the runner (Thompson & Sherman, 1993).

Furthermore, since individual scores are summed together

for a total team score, team members may encourage one

another to maintain a low weight in the interest of the

group.

Eder and Parker (1987) also found that among mem-

bers of female athletic teams, there are numerous interac-

tions regarding appearance and body image. In addition,

there is a positive correlation between teammate influences

and changes in eating or dieting behaviors (Hausenblas,

2000). This “Do it for the team” mentality may cause ath-

letes to feel responsible for not only their own place on the

team, but for the competitive status of the team as a whole.

Accordingly, many successful athletes view successful,

slim athletes as role models for body-related attitudes and

behaviors (Burckes-Miller & Black, 1991). Further, since

many cross-country, gymnastics, swimming, and diving

teams (among others) traditionally have team dinners be-

fore competitive events, athletes may adapt their eating

styles to resemble those of their calorie-restricting team-

mates (Thompson & Sherman, 1993).

The Female Athlete Triad

Eating disordered behavior can adversely affect multi-

ple organ systems, sometimes with permanent or even fatal

consequences. The Female Athlete Triad is a term used to

describe the three-fold condition of disordered eating, ame-

norrhea, and osteoporosis that commonly occurs in physi-

cally active girls and women. There are many causes of the

Triad, but the pressure placed on young women to achieve

or maintain a low body weight is often cited as an over-

arching force in development (Otis, Drinkwater, Johnson,

Loucks, and Wilmore, 1997). The greatest risk for the de-

velopment of the Female Athlete Triad occurs in aesthetic

sports that emphasize a lean physique or appearance (e.g.,

ballet, gymnastics, and figure skating), and in performance

sports where coaches and athletes believe that lower body

fat enhances performance (e.g., running, cross country, and

swimming; Berg, 2000).

Amenorrhea is classified as either the absence of men-

struation by age sixteen (primary amenorrhea), or the ab-

sence of three or more consecutive menstrual cycles after

menarche (secondary amenorrhea). Amenorrhea linked to

eating disorders or exercise is hypothalamic in origin, and

results in decreased ovarian hormone production and hypo-

estrogenemia. In a 1996 study conducted by Fogelhom,

Lichtenbelt, Wouter Van Marken, Ottenheihm, and

Westerterp in the Netherlands, examining the prevalence of

amenorrhea among 113 professional and student ballet

dancers (mean age = 23.3 years), it was found that two

dancers had primary amenorrhea, and 9.8% of those not on

oral contraceptives had secondary amenorrhea. Other stud-



BERNSTEIN

66

ies have also found a high risk of amenorrhea in ballet

dancers. A meta-analysis conducted by Fogelhom and col-

leagues (1996) revealed a mean prevalence of amenorrhea

in ballet dancers of 31.4%. In addition to amenorrhea,

many dancers described in these studies also faced men-

strual irregularities. Similarly, Benson, Bourdet, and Loosli

(1985) found that 55-67% of ballet dancers had irregular

menstrual cycles.

The Sports Environment, Healthy Eating, and Body Image

The sports environment is both a protective and risk

factor for the development of eating-related behaviors in

women. In some situations, participation in sports is pro-

tective and fosters a positive body image. According to

Hausenblas (2001), women who play sports are more

trusting of other people, have positive body image, and

have higher self-esteem. In a study with 114 female high-

school aged participants (athletes and non-athletes)

Hausenblas (2001) found several differences between the

two groups. Specifically, compared to the non-athletes, the

athletes in her study reported feeling 53% more in control

of their lives. The athletes also conveyed a higher body

image than those who did not engage in any sort of athletic

activity, and 31% of athletes experienced lower levels of

body dissatisfaction. However, the type of sport must also

be considered. Sports that highlight physical stature,

strength, and power tend to favor athletes who are taller

and heavier. Studies have shown that from age ten years,

female rowers and soccer, basketball, softball, volleyball,

and hockey players exceed the 50
th

 percentiles of the fe-

male reference population in physical build (Malina, 1994).

However, other sports such as gymnastics, figure skating,

diving, cheerleading, and ballet promote aesthetics along

with technical ability, rewarding the smaller athlete. These

thin body build (TB) sports reinforce the importance of

slenderness, equating low body weight and a small body

size with optimal athletic performance (Patel, Greydanus,

Pratt, & Phillips, 2003).

Research has suggested that females who participate in

sports where appearance is emphasized (such as those

noted above) are at an increased risk for developing eating

disorders. Borgen and Corbin (1987) found that more ath-

letes in the TB sports had Eating Disorder Inventory scores

(Garner, Olmsted, Polivy, 1983) similar to or above those

of individuals with AN. Otis et al. (1997) outlined some

common guidelines shared by the TB sports, further ex-

amining how the nature of these sports perpetuates the risk

for eating disorder development. These ‘at-risk’ sports in-

clude a diverse group of activities: endurance sports, sports

where an athlete’s performance is subjectively scored by

judges, sports where athletes are required to wear revealing

clothing, sports using weight categories for participation

(horse racing, some martial arts, wrestling, rowing), and

sports that idealize a pre-pubertal body type (figure skating,

gymnastics, ballet, diving). The typical female athlete par-

ticipating in a TB sport confronts body image pressure at

multiple levels. Athletes in sports like gymnastics and long-

distance running reported a greater sense of body dissatis-

faction than both non-athletes and those participating in

non-thinness-demand sports, despite weighing significantly

less than both the other groups (Davis & Cowles, 1989).

In the figure skating world, in particular, elegance and

grace are foremost associated with thinness. Professional

skaters performing on ice sometimes receive reduced pay

for being ‘overweight’ (Thompson & Sherman, 1993).

Skaters who are unable to achieve or maintain the physical

ideals of the sport often experience negative affect, which

in turn may cause attempts to control body size through

disordered eating (Harris, 1986). For competitive pairs

(male-female partner) figure skating, a lean female body is

an unspoken requisite to compete. Pairs competitions re-

quire the male to lift, throw, and maneuver the female into

difficult positions in the air; these acts can be physically

straining and cause injury to both partners. Thus for practi-

cal, physical, and aesthetic purposes, it is important that the

female partner be lightweight.

In their study on the symptomology of eating disorders

in Canadian competitive figure skaters, Taylor and Ste-

Marie (2001) found that 92.7% of the forty-one skaters

surveyed reported pressure to lose weight. The skaters also

indicated that in efforts to maintain the thin ideal, they en-

gaged in various weight control measures such as vomiting

and/or restrictive dieting at some point. After extensive

clinical study of eating disorders in non-athlete women,

Rezek and Leary (1991) determined a relationship between

self-restricted eating and perceived locus of control. Since

figure skating is an aesthetic sport where outcomes are

controlled subjectively by judges, athletes may reconcile

their perceived lack of control over performance with re-

stricted eating.

According to Scourfield and colleagues (2003), a

goodness of fit exists between an individual and his/her

environment. In other words, people seek out contexts or

environments that match their psychological and genetic

dispositions. Applying the goodness-of-fit hypothesis to the

prevalence of disordered eating in female athletes, one can

hypothesize a “goodness of fit” between an athlete and her

chosen sport. Some researchers have suggested that athletes

who are predisposed to developing an eating disorder tend

to self-select a certain type of athletic activity, a phenome-

non known as the “self-selection” or “sport-attraction” hy-

pothesis (Thompson & Sherman, 1993, p. 25). Accord-

ingly, an individual scoring high on the EDI may idealize

the graceful, fragile-looking prima ballerina, choosing to

emulate both the ballerina’s body type and intense training

regimen. In their study of female runners, Estok and Rudy

(1996) found that 25% of women who ran more than 30

miles per week had high Eating Attitudes Test scores for

Anorexia or Bulimia. When asked what had initially drawn

them to the sport, the eating disordered women indicated

that they were attracted to running because it represented a

salient image of thinness. Since high EDI-scoring individu-

als often display controlled, obsessive, and perfectionistic



EATING DISORDERS IN FEMALE ATHLETES

67

types of behaviors, it is not surprising that they choose to

participate in athletic activities in which these behaviors are

encouraged.

Eating Disorder Identification Issues in the Female Athlete

Populations

The sports environment has the potential to trigger,

worsen, or legitimize an eating disorder in vulnerable indi-

viduals. In this context, eating disorder diagnoses are com-

plicated by the fact that some athletes are relatively satis-

fied with their bodies and do not meet the DSM-IV-TR cri-

teria for “fear of becoming fat.” However, they may still

engage in unhealthy dieting or eating behaviors due to a

perceived belief that their success in the sport depends on

their attainment of a low body weight or fat content.

Ziegler and colleagues (1998) found such a paradoxical

weight-related concern in a study of junior elite figure skat-

ers who ironically reported positive body image. The skat-

ers were not dissatisfied with the shape of their bodies, yet

strove to reduce weight either gradually (by dieting and

exercising) or rapidly (by vomiting). However, since ‘body

dissatisfaction’ is at the core of most eating-related issues,

such athletes cannot clearly be diagnosed with an eating

disorder despite their unhealthy eating behaviors.

The drive for thinness in female athletes may come

from a different source. Many sports, particularly those at

the elite level, stress the message of “no pain, no gain.” It is

not surprising then that male and female athletes of com-

petitive sports often take drastic measures to succeed, in-

cluding training during physical injury, using steroids, and

losing/gaining weight over a short period of time. In this

regard, the sports environment often portrays success as the

end result of a long journey of arduous physical work and

strain. While female athletes may not necessarily wish to

lose weight, they may do so because they believe it will

maximize chances of winning or accomplishment. This

‘light at the end of the tunnel’ effect may make it easier for

athletes to hide or justify weight-related issues, which in

turn stalls identification and proper treatment of eating dis-

orders (Thompson & Sherman, 1993).

Another issue informing the identification of eating

disorders lies in the exercise component of the sport itself.

How does one determine how much exercise is too much?

At the elite level, it is customary for athletes to train for six

or more hours a day. Athletes with BN may use such rigor-

ous exercise as a vehicle to maintain the disorder. Regard-

less of whether exercise is designed to enhance perform-

ance, athletes with BN may look to excessive exercise as a

weight loss tool that can undo the effects of bingeing. For

example, after bingeing, a cross-country athlete with BN

may run 6-8 miles to punish herself for “being bad”

(Thompson & Sherman, 1993, p. 89). Such maladaptive

behavior may go unnoticed by parents, coaches, and team-

mates who see the athlete as dedicated rather than disor-

dered.

Certain personality traits found in good athletes and

individuals with AN are found to correlate with one an-

other, further complicating proper eating disorder diagnosis

(Thompson & Sherman, 2001). Both elite athletes and in-

dividuals with eating disorders are often willing to work to

the point of overwork, have a high need for achievement,

are selflessly committed to their team, comply obligingly

with coaching instructions, are able to endure intense

physical discomfort or pain, are willing to lose weight in

order to enhance performance, and are perfectionists

(Thompson & Sherman, 1993).

The similarities that exist between hard-working ath-

letes and eating disordered individuals were further illumi-

nated in a study conducted by Yates, Leehay, and Shisslak

(1983). The researchers compared the behavior and demo-

graphics of 60 male marathon and trail runners to a sample

of women with AN, drawing parallels between the two

groups. Yates and colleagues found that the obligatory run-

ners resembled the anorexic women in familial back-

ground, socioeconomic class, and several personality traits.

Like the male athletes, the women with AN displayed high

self-expectations, demonstrated tolerance for physical dis-

comfort, denied potential physical debilities/injuries, ex-

hibited an inhibition of anger, and showed a tendency to-

ward depression. Although the results of this study were

controversial, it demonstrates an association of trait simi-

larities shared among athletes and individuals with AN.

Impact of Coaches on Eating Disordered Behavior

In certain sports that emphasize a lean body type,

coaches have been found to increase the risk of eating-

related disturbances through some of their attitudes and

behaviors (Heffner, Ogles, Gold, Marsden, & Johnson,

2003). Coaches may assume that reducing body fat or

weight can enhance an athlete’s performance, and may

encourage rapid weight loss (Thompson & Sherman, 1993).

It is important to note that many elite athletes also begin

their vigorous training at a young age. During this period of

primary growth and development, the athletes spend sev-

eral hours a day with coaches who may often advocate un-

healthy or restrictive eating practices.

Coaches’ disparaging comments may catalyze disor-

dered eating behaviors. Rosen and Hough (1988) re-

searched the eating behaviors of 42 female gymnasts on

five college teams, finding that 67% of the gymnasts were

told by their coaches that they were too heavy. Of this

group, 75% reported that they frequently engaged in patho-

genic methods (vomiting, laxative abuse, diuretics, diet

pills, fasting, and fluid restrictions) to control their weight.

In a similar study, Burgess (1995) found that a gym-

nastics coach’s personality directly corresponded to the

number of team eating-related issues. The researcher found

that in relation to personality, the coaches of eating disor-

dered collegiate gymnasts were narcissistic, inflexible, and

high in dominance traits. While these studies provide inter-

esting evidence, they do not produce answers to causal



BERNSTEIN

68

questions regarding the relationship between coaches and

their gymnasts. Perhaps the athletic environment, another

potential causal factor, is responsible. It is possible that the

intense, high-stress atmosphere of collegiate-level compe-

tition cultivates strong personality traits in coaches and

eating disordered behavior in athletes.

Intervention and Treatment Strategies for Female Athletes

with Eating Disorders

Given all that is known about the ways in which eating

disorders are manifested in female athletes, treatment needs

occur in the form of intervention and therapy. Treatment

should not be limited to athletes—coaches and parents need

to be educated about eating disorders as well. Since a coach

serves as an instrumental authority figure to an athlete’s

success, it is important that he or she approach weight loss

in a healthy, constructive way. A positive, authoritative

coach can assuage risks for eating disorder development

and promote a healthy body image in his or her athletes.

The effects of a positive coaching style have been

demonstrated by Bisecker and Martz (1999) in their study

on the impact of coaching style on athletes’ eating prob-

lems. After assigning 110 male and female college athletes

to a negative or a positive coaching vignette condition, the

researchers measured body image anxiety and eating-

related disturbances. In the negative vignette condition, the

coach was performance-centered and focused on issues of

weight in a threatening and controlling manner. While the

coach also stressed low body weight in the positive vignette

condition, he behaved in a problem-centered, caring man-

ner. Bisecker and Martz (1999) found that regardless of

gender, participants in the negative vignette condition

showed higher instances of dieting, body image anxiety,

and fear of becoming fat.  Although participants in the

positive vignette condition still dieted, they did so in a

healthy manner, and did not exhibit the same pathogenic

behaviors as the participants in the negative coach condi-

tion.

Approaching dieting in a problem-centered way makes

it so the athlete does not feel threatened or attacked.

Coaches of all backgrounds and coaching styles should be

informed about proper nutrition, the daily caloric require-

ments of athletes, healthy dieting behaviors, and the differ-

ent types of eating disorders and their respective risk fac-

tors.

Although it may be difficult to confront an athlete

about a potential eating-related problem, interventions

should be led on a collective level by parents, trainers,

coaches, and members of the sports management team.

Although the athlete may be resistant to treatment and in

denial of her eating disorder, proper action must be taken.

Such protocol would ideally require every athlete to un-

dergo regular medical examinations. If these examinations

reveal extreme weight loss or signs of other health condi-

tions, then critical steps must be taken to protect the ath-

lete’s health. These steps may include the termination of all

training until the athlete’s health improves.

A team of qualified sports psychologists, medical pro-

fessionals, and nutritionists must closely monitor an athlete

suspected of an eating disorder. It also may be beneficial

for an eating disordered athlete to begin therapy sessions

with a licensed psychologist to successfully address the

root of her eating problems.

Conclusion

Despite generally representing a healthful atmosphere,

the sports environment can serve as a potential host for

eating disorders. Although eating disorders are more

prevalent in aesthetic or appearance-related activities or

sports, the Female Athlete Triad does not discriminate in its

damaging effects. Some athletes’ perfectionist personalities

may make them more disposed to disturbances in eating,

which are only exacerbated by the influences of authori-

tarian or weight-obsessed coaches. Eating disorders need to

be addressed on the team, coach, familial, and individual

levels to prevent serious bodily harm. Therapists, nutri-

tionists, and sports psychologists should be available to all

athletes regardless of the athletes’ eating disorder status.

Similarly, sports teams should be required to attend semi-

nars geared at eating disorder recognition, intervention, and

treatment at the start of a sports season. On the team level,

this experience could endorse group bonding and camara-

derie, as it serves as a way for athletes to better understand

and help one another. To prevent the irreversible conse-

quences of eating disordered behavior in female athletes,

parents, trainers, and other members of the sports commu-

nity must work together to foster a truly healthful environ-

ment.

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