Emetophobia and Why Purity Culture Won’t Save Us

There is a belief that healthy lives are rewards for correct behavior, and illness and death are earned through insufficient devotion.

1.

It is a strange truth of my life that the battleground on which my tussles with God played out was a bathroom. I don’t remember praying much anywhere else. I kneeled down on what I’ve come to think of as my prayer rug—a worn green mat, U-shaped to accommodate the curve of the toilet and bald where I had plucked at the yarn. Quivering in a cold sweat, I clutched at my own arms until nails punctured skin in little red half-moons. I prayed through grinding teeth for reprieve: Protect me. Help me beat this. I’ll be so good. Perhaps the bargains I made pleased God; for year after year of my childhood and adolescence, my prayers were somehow—Glory Be!—answered. Often it was not until the sun crept over the windowsill that the nausea abated and I curled myself around the toilet for an hour of sleep before school.

The clinical term is emetophobia: fear of vomit and vomiting—and whether it’s mine or yours, it doesn’t much matter. It is a specialized anxiety and panic disorder, and anxiety and panic, as you may know, often occasion further stomach upset. The banal twists and turns of healthy digestion are therefore rendered sinister by my circular thoughts and obsessive self-vigilance. Did I drink that wine too fast? Is that a stitch in my side? Am I sure that chicken breast was completely cooked? Oh no! I’ve chosen the worst possible airplane seat for turbulence and there is no airsickness bag within reach and . . . WHY CAN’T I SWALLOW???

Along with the panic come all the attendant physical symptoms, and round and round we go. To this day, the smell of Comet scouring powder, which my mother used faithfully, works like a kind of olfactory Pavlovian trigger, cuing a tide of panic that emerges from somewhere within the gore of me; not the surface-level jitters of job interviews and too-much-caffeine, which radiate out from the skin, but the weighty terror that somewhere in the depths of my organs and marrow lies a prophecy unrealized. It is the sense, only occasionally brushed upon and always by accident, of the body as a gateway to an abyss, of the body as a well and truly capricious thing that, no matter how disciplined, ultimately refuses domination.

If one is willing to dedicate many sleepless hours to the endeavor, engaging every muscle, breathing only in very shallow sips, and squeezing at acupressure points in the inner wrists, it’s possible to avoid the act almost entirely, keeping the morbid fear at bay, one day at a time. These are the tricks I learned after I lost my religion one night at the age of twelve. My mother had on that occasion been awoken by my whimpering and my frantic pacing about, and she looked on, bleary-eyed in nightgown and dense glasses, as I struggled against and then succumbed to a stomach bug that had been going around school. I vomited into the bathroom sink. Afterwards, she set about cleaning up my mess, while I spit repeatedly into a tissue and swallowed the new unwelcome truth of that day: God had let me down. I was without accomplice in the fight against my body.

A short time later, I whispered out loud to Him I don’t believe in you, though in truth I was not yet convinced that I didn’t. I had many doubts, certainly. That night, soaking in a lukewarm bath where I had spent hours alternately contemplating the afterlife and the way my swelling chest interrupted the surface of the water, I suppose it was a brief fit of petulance that moved me to officially register my blasphemy. Or perhaps it was simply an experiment: Speak the unspeakable for the first time in my life and see if the world didn’t crumble around me.

In any case, God did not hear it that way. Just as the words left my mouth, I stood, and I slipped. Kneecap struck chrome faucet, producing an unnatural crack. Beneath the pain I felt some tectonic rift open up within me, indelible and unmistakable, even to a twelve-year-old. I pressed my face into the green mat, sobbing not for the physical pain but for some less precise one. At the very moment God revealed Himself to me—leaving me little doubt as to His existence—I understood that I had, with my bold pronouncement, gone and disqualified myself from being worthy of belief. My education had prepared me to intuit as much.

In the years before the bathtub incident I’d flirted with a career as a religious tyrant. This was not unusual; in my small-town Christian community, sinning (so far as we understood the concept) was not dissimilar from wearing “high water” pants or being fat or soiling oneself: an unfortunate choice with grave social consequences. There was a hierarchy, naturally, and the devout were perched at the top. It was our crude replica of the adult realm, in which religion was used to bludgeon others into conformity and sin’s infectious properties were greatly feared.

What we lacked as children was a facility for nuance, and the concept of redemption was beyond our reach. I remember a few Sundays during which a former Hell’s Angel or drug addict or convict—big burly men, always, in my recollection—took to the stage of our church’s auditorium in their tired denim and their belt buckles to speak of being “born again.” I stared in wonder at the fat tears and trembling hands that filled the frame of the jumbotron and felt a flickering uncertainty. I’d read all the Left Behind books, after all, and I’d had the predictable Rapture nightmares, and so I knew that there was little room for error; only an immaculate life would do. My fellow crusaders and I thought of ourselves as heroes, in a sense, because in identifying those classmates who were going to hell—blasphemers, cheaters, petty thieves, potty mouths, etc.—we could save the others from lying down with the dogs.

I launched a smear campaign against a candidate for class president, a boy who had foolishly admitted, to someone, somewhere along the chain of gossip, to having “jerked himself off.” The scandalized moral majority shunned him. In another shameful memory, I am spinning on a tire swing with two other ten-year-olds: a white girl, who is my neighbor and friend, and a black girl, whom I have not known long. The white girl and I have picked up on certain vibes coming from the black girl, but she is smart enough to never admit what we know instinctively to be true. It is only after the white girl and I have conspired over the course of several weeks to befriend her, gain her trust, and draw her out that we win the quarry we had so desired: a confession. After we’ve outed her to the authorities and she has been sufficiently dealt with, our mothers will regard us as the victims of some kind of troubled predator, and we will not contradict them.

Adolescence is a tough time for fundamentalism. Desire, once an incomprehensible abstraction, becomes concrete when puberty sets in, and the Central Organizing Structure of a religious tween’s life comes under siege. Sex is often the fulcrum that propels young people away from sunny Bible songs and paper cutouts of Noah’s ark and towards a more adult decision-making process, full of weighted pros and cons, regarding the acceptance or rejection of God. But it’s painful to surrender childish ideals in favor of grown-up gray areas and inconsistencies—you can see how tortured this process is if you watch the hysterics with which teenagers worship. For me, and I suspect for many others, there was a frenzied last grab for purity, and a sense that if you could outrun your classmates then that was at least sufficient to stave off the bear for the time being.

All that to say: perhaps there are many reasons why I lost God at the precise moment I did. But whatever the reasons, when my Central Organizing Structure collapsed, I had to compose another one on the fly. Without God’s assistance, my life-long campaign to forestall any gastric event would require a new kind of purity, enforced with the same Puritanical personal responsibility in which I was already well-versed. I held my breath when walking through the crowded school hallways, devised strategies to avoid touching door handles, and examined food expiration dates with exceeding care.

2.

The FDA banned nineteen chemicals used in antibacterial soaps because manufacturers could not prove that they are any more effective in preventing the spread of germs than plain soap and water, and because we neither understand the impact of widespread antibacterial use on the creation of resistant bacteria strains nor the effect of these chemicals on the environment. Evidence of the body’s microbiome as an ecosystem thriving on diversity has been mounting of late, and the public seems to be responding with a subtle shift in mindset. The American obsession with purity is far from dead—two million honey bees were killed in South Carolina, casualties of a bombing aimed at a handful of suspected Zika-infected mosquitoes—but our relationship to it is indubitably evolving.

Growing up, I lived in one of those suburban homes with eerily perfect angles—its granite countertops and wood floors Lysol-ed to a shine, its air maintained by gently humming purifying machines, its white hypoallergenic carpet laid to dull the edges of sharp stairs. What strikes me most about the memory of those pristine spaces is the shock of small creatures, anyway—of roaches, spiders, and on one occasion, a mouse. My grandfather, who had fought in enough wars to know the importance of ruthlessness in confronting enemy infiltrators, broke the mouse’s back and flushed it away. My brother and I dutifully Lysol-ed the spot where it died.

Evil is unwieldy, and so control must be uncompromising. The weeds will tumble over the curb; the ants will learn to pick locks if that’s what it takes to get into the pantry. In eastern North Carolina, there is such a thing as a “caterpillar year,” in which the caterpillar population is inexplicably outsized. One such year, they blanketed our yard and penetrated our fortress; we smushed hundreds of them into pulp on our way up the driveway, and poured the fuzzy little things—which resembled writhing incarnations of textbook germ illustrations—out of cereal boxes.

It is precisely because purity is so fragile that purity is also so ruthless. We measure the number of babies against the filth of the bathwater and come to some professional conclusions. It is for this same reason that I embraced my own absolutisms. I abruptly ended relationships with playmates who had unpredictable digestive tracts. Boats would always be categorically out of the question, as would, in later years, frat parties past a certain hour. I researched the vomit content of movies before I would agree to watch them, and scrutinized restaurant health grades. A security scanner program whirred 24/7 in the background of my life, sapping energy as I consciously and subconsciously maneuvered to maintain the peace of a life unsullied.

Eula Biss poignantly characterizes in On Immunity how our society has in large part traded our paranoia over “filthy” organic infection agents for paranoia over “toxic” industrial pollutants. Evil has indeed been recast, but for that matter so has purity: where once we sought to eradicate all bacteria by sealing our bodies off from the natural world, now we invite certain “good” or “pro” bacteria to flourish, swallowing them in neatly encapsulated doses. We believe that we can populate an ecosystem with only that which is pleasant to us, and dispense with all the rest: the forest without the wolves, the swamp without the mosquitoes, the subdivisions with the carefully selected species of sod. We arrogantly assume ourselves capable of definitively parsing the good from the bad, when nothing in our social or scientific history should indicate that these categorizations will not change over time. We have always known “good” and “bad” immigrants, though the latter were once Italian, were once Chinese, are now Syrian. We’ve at turns banished fat, carbs, sugar, and gluten.

In the last pages of his often-painful autobiography, John Updike refers to himself as “an amiable, reasonable, interested, generally healthy, sexually normal, dependable, hopeful, fortunate human being . . . which goes to show,” Updike writes, “what a vexed thing even a fortunate human being is.” These are admittedly small tragedies—all the living we relinquish to sate our hunger for control, all the time and energy wasted in elaborate schemes to deny the inescapable truth. And though I’ve never been cured of my emetophobia, as I’ve gotten older I’ve come to see my own condition as merely a mutation on a genus of anxieties so common they affect nearly all of my friends, too. None of us are entirely free from the small tragedies. In fact, I’ve never felt less alone; everyone in my milieu embraces their own fundamentalisms.

3.

Picture a long table under a wedding tent. I am in the middle. To my left is a vegan couple evangelizing the benefits of the plant-based diet to meditation (it’s possible to “reach a whole other plane of consciousness,” apparently). To my right is a couple chatting animatedly with another woman who is, they have discovered, a fellow Crossfitter and member of the paleo diet tribe. These three, who have in front of them clean plates save for identical little piles of rejected rice, all pull out their phones to compare the weeks’ food consumption on their MyFitnessPal apps. I am not a cavewoman and so am excluded from the conversation, such as it is. I nibble on a gluten-free doughnut, which has been offered in lieu of wedding cake, more concerned about how long the food had been sitting out before it was served than its macronutrient content.

Eating has always been a social activity; dieting rarely has. But as the ostensible goal of dieting has shifted from getting skinny to obtaining a magical state of purity capable of transforming energy levels and warding off cancer, it has become acceptable to recruit others to our various ideologies. This new pastime serves a narcissistic purpose, which is to distinguish our class by way of our style. The tribalism of modern dieting often seems like it’s no more than brand loyalty—a sort of keeping up with the Joneses for a generation that doesn’t care much for picket fences. But while classist one-upmanship is undeniably at play, it would be all too reductive to put this phenomenon down to egomania alone.

Status anxiety does not buzz at quite this pitch. While good taste typically necessitates a distancing of oneself from the gauche preferences of the hoi polloi, there prevails an earnest sense of urgency to dietary evangelism. Lives are at stake! Repent, get clean, get wholesome—save yourself! In an increasingly secular and cynical nation, one might compare the “clean eating” hacks to priest surrogates—our updated Central Organizing Structures, disseminating neatly packaged guidelines for correct behavior, and thus, salvation.

I, too, maintain a deeply embedded belief that happy, healthy, long lives are rewards for correct behavior, and that illness, misery, and death are likewise earned through insufficient devotion. This conviction seems to reinforce itself even as the evidence against it mounts; in our era of climate change and stagnated wages, an era that simply does not necessarily reward personal responsibility as it once did, many people are doubling down on “clean eating” and work ethic and “social business” in an attempt to convince themselves that the system is working just fine.

Increasingly I wonder whether the obsession with dietary purity, with not fucking up even one single meal, owes something to the fact that “good enough” is no longer quite good enough. Well-paying jobs, financial security, and retirement are not available to every middle class professional with a great work ethic, so one had better outcompete everyone at the office. One’s children, similarly, must benefit from the most optimized education so that they may go on to win every spelling bee and science fair. Perhaps our conviction that only the most deserving can hope to dodge cancer and our resulting terror of less-than-optimal nutrient input are only the natural extensions of this tortured mentality.

It’s telling that the ethical considerations of diet are out of vogue; we are largely more concerned with how veganism benefits us—reflecting, I think, a nihilistic conviction that we are too powerless to bother with larger sociopolitical trends. Perhaps we broadcast our diets to build a community of support as we struggle individually towards salvation. Even so, I find the idea of a society that has swapped political advocacy—in favor of, say, cleaner water or affordable healthcare that could better support us when we do fall ill—for juice cleanses so grim that it almost makes me pine for the vegan old guard.

In Barbara Ehrenreich’s “Welcome to Cancerland,” she rages against “the mindless triumphalism of ‘survivorhood’ [which] denigrates the dead and the dying.”

Did we who live ‘fight’ harder than those who’ve died? Can we claim to be ‘braver,’ better, people than the dead? And why is there no room in this cult for some gracious acceptance of death, when the time comes, which it surely will, through cancer or some other misfortune?

I’d add to this list of questions: Are we so thoroughly brainwashed as to conceive of living itself as a purely meritocratic endeavor?

4.

At my fourth cognitive behavioral therapy appointment, I sit in my therapist’s ergonomic office chair while she hovers behind me, occasionally purring encouragements. There is a trashcan just three feet away from me, in case I need it. Every few minutes, she reaches over to direct the mouse to the next slide, which is a new image of vomit or vomiting that is ever so slightly more distressing than the previous image. Vomiting is just a reflex, she says. It cannot be controlled, and we are learning to accept that. I stare at the screen and try not to blink. We have moved beyond cartoon images, and so I am looking at a photo of a real, live blond woman who is hovering over a toilet, her right hand clutching the back of the seat. A doorway frames the photo, as if I’m standing just far enough away to avoid contamination. This reminds me of how, during our first session, my therapist asked me what the evolutionary explanation might be for emetophobia. It took everything I had not to roll my eyes at her. Pathogens, filth, impurity, disease, death—did she think I was so deeply un-self-aware that I couldn’t even connect those dots?

I am thirty-one years old and, at the time of writing, fourteen years clean. I can remember vomiting exactly 3.5 times in my life, since on one of those occasions I was high and sleep-walking toward the bathroom; I awoke to a pile of vomit hitting my prayer rug and just narrowly missing my feet, with no memory of it leaving my mouth. In my world, these fourteen years are a great victory, though they are of little consolation next to the bevy of proxy symptoms—which at times resemble claustrophobia, social anxiety, hypochondria, and OCD—that are the price of my years of purity. The panic attacks continue; each time I become convinced for no reason at all that my fifth vomiting experience is imminent.

The favored psychological technique for combating phobias is a process called “immersion therapy”—the photos become audio clips, which lead to video, and all the while the escalating sensory experiences are supposed to be normalized, until finally I am able to vomit myself. Staring at the photo, I feel my own mouth fill with saliva, as the blonde woman’s mouth must have. Something seems like it’s rising in my chest, and I begin to sweat. I tell my therapist as much, and she reminds me that my problem derives not from real sickness but from a neurotic hyperfocus on the self. It’s no use, though. I’m choking. I’m right on the edge.

5.

The most terrifying thing about being an atheist is that I don’t walk around with the conviction that somebody else has a plan. A friend who is a doula and midwife’s assistant tells me that her absolute best patients are the religious ones, because if anything goes wrong with the birth or the baby, it is never her fault. “God works in mysterious ways,” they will say. A good Christian knows that, so long as she is pious, following all of God’s rules, He will take care of her in the best way He knows how, whether that means giving her a beautiful, healthy baby or calling both her and the baby back to Heaven. I have subscribed to the Puritan-capitalist gospel of personal responsibility, but without the divine oversight or the celestial rewards for obedience.

If one does not believe in God, does not trust the state, does not for a second ascribe any virtue to business, and doubts even the efficacy of personal responsibility, then where does one look for healing and grace? When I am feeling powerless and alone, I go for a run, perhaps an unabashedly hypocritical and nonetheless utterly predictable thing to do.

I’ve never fully recovered from my bathtub knee injury, which is unfortunate because running is the only suitable surrogate for prayer I have ever encountered in my life. I discovered it as a teenager and embraced it like a true zealot. Whenever my knee was cooperating, I ran on 100-degree summer afternoons and 20-degree winter nights, ran until my vision blurred, ran until I was dizzy, and then came home and lay flat on my back, watching the ceiling spin over my head. Running could be a kind of purifying force, a redemption from dietary transgressions but also from other shames. Whenever I was slighted, hurt, insufficiently loved, or inadequately appreciated for my power and grace, there were my shoes, lying in wait by the door; there was the road out there somewhere, pulling me towards it. In my mind I proved them all wrong on the trail. I would leap high over a fallen tree, landing on the other side into a stride as fluid and uninterrupted as a deer’s, and think, yes, and what of me now? At times it has felt very much like running was the only thing at which I excelled.

The body is the atheist’s only temple, and if there can be some spirituality within atheism, it requires the permission and the complicity of the body. Spiritual atheists can meditate on the vast and eternal character of a universe in which all things are connected, attempting to lose the significance of themselves as individuals as they strive to “become one.” But it’s impossible to forget that “soul” is believed to be a mystical name given to the intricate functions of physical matter, our brains. Death is a hard stop for spiritual connection; our conscious selves can only benefit from union with the universal organism for as long as our bodies continue to supply our brains with oxygen. Our bodies are our Gods. To commune with them, to nurture our relationships with them, is to pray to that which gives us life and meaning.

With running I do not seek to transcend anything, but to pound myself with each step deeper inside of my own existence. When I run, my body and I feel like allies, giving me a comforting sense of control over—or at the very least awareness of—its goings-on, even if I know intellectually that that sense is ill-founded. But God was clever and had made sure He would not so easily be forgotten. My knee, which had been knocked violently out of its proper place, would never again be what it was, and so my pseudo-spiritual communion with my body—perhaps my best bet for quieting the morbid fear—is thwarted when my knee stages its intermittent revolts, increasingly common over the last few years, often forcing me to give up not only running, but also biking, yoga, high heels, and, on occasion, stairs. My physical therapist teaches me the stretches and the exercises, using resistance bands and workout balls and balance boards, and tells me that if I’m devoted I will someday run again.

I’m back at it again after almost two years without running, and I’m reminded that there’s something sinister here. It scares me how little self-control I seem to have; I struggle mightily to muster the discipline needed to curb my mileage for the sake of my knee’s long-term health. If I have ever flirted with any addiction, it was this, and I was particularly afflicted during my years of chronic underemployment. (During which, in an attempt to bend the universe to my will, I also staged several private hunger strikes.)

“Nothing can make you believe we harbor nostalgia for factory work but a modern gym,” writes Mark Greif. I ran to escape the fear that I would never amount to anything, to chase a feeling of virtuous productivity with every step, and so five miles sometimes became fifteen. Though I have promised myself no more marathons, today as I circled Fort Greene Park I found myself searching for a way to justify doing just one, just one, before the year is out.

But then it’s hard to parse, exactly, what the relationship might be between corporate success and bodily obsession. I watch on social media as a good Spanish friend of mine, whom I have always known to be thin without trying, suddenly takes up Bikram yoga, veganism, and distance-running shortly after she’s acquired one of the few very well-paid jobs in Spain. I say a little prayer for her, and I wonder: Is a corporate office petri dish really all it takes? Is the meritocratic mindset so infectious?

Writes Mark Greif:

The most onerous forms of necessity, the struggle for food, against disease, always by means of hard labor, have been overcome. It might have been naïve to think the new human freedom would push us towards a society of public pursuits, like Periclean Athens, or of simple delight in what exists, as in Eden.

6.

My therapist has left the room momentarily, and so I sit alone next to the white noise machine, shaking. She has asked my permission to go fetch a bowl of vomit, which she will then place on a table between us. At first I wonder how and from where she will obtain this vomit, but I don’t much like that train of thought, and so to distract myself while I wait, I scroll through the Times app. Representative Mo Brooks from Alabama has angered people, it seems, with his claim that insurance companies should be allowed to charge more for preexisting conditions.

It will allow insurance companies to require people who have higher healthcare costs to contribute more to the insurance pool that helps offset all these costs, thereby reducing the cost to those people who lead good lives. They’re healthy; they’ve done the things to keep their bodies healthy. And right now, those are the people who have done things the right way that are seeing their costs skyrocketing.

My therapist returns, and the closing door sends a blast of air in my direction. The smell is unmistakable: canned soup. I don’t want to hurt her feelings by laughing, and so I level a serious gaze at the chunks of tomato and green bean floating in a white Tupperware. She asks if I think I might be capable of holding it in my hands. I am, and so I do. My insurance doesn’t cover these sessions; if I felt up to it, I could do the math and discern exactly how much each minute that I sat there holding fake vomit in my hands was costing me.

I have led a good life, I want to tell her. I have ‘done the things’ in the ‘right way.’ So how the fuck did I get here?