"A possible reason for this is that the behavior is not socially acceptable," Dr. Kathryn Kinmond, a senior lecturer from the Health, Rehabilitation and Psychology center at Manchester Metropolitan University, told me over email. CHSP is not referenced anywhere near as often as anorexia or bulimia in films and TV shows, there are no celebrities associated with it, and it often doesn’t result in pictures shocking enough for the tabloids. Most importantly, it’s harder for professionals to study, because, as Dr. Kinmond noted: "It is largely a hidden disorder, in that people are not hospitalized for chewing and spitting."
In 1988, psychiatrists at Minnesota Medical School first examined chewing and spitting as a clinical feature of bulimia. Since then, a variety of studies have found that people living with anorexia, especially those with the most severe cases of the disease, also engage in the behavior. But even though 24.5% of eating disorder sufferers have been found to chew and spit, it was called a "neglected symptom" in the International Journal of Eating Disorders as recently as 2006. The U.K.’s leading eating disorder charity, Beat, told me, "It doesn’t really come into our remit at the moment," because it is considered a symptom, not a disorder in its own right.
Up until 2013, chewing and spitting was featured as a symptom of Eating Disorder Not Otherwise Specified (EDNOS) in the Diagnostic and Statistical Manual of Mental Disorders. One example of EDNOS behavior in the DSM-IV was "repeatedly chewing and spitting out, but not swallowing, large amounts of food." However, EDNOS was replaced by "Other Specified Feeding or Eating Disorder" (OSFED) in the DSM-V, and there is now no mention of CHSP at all. Like Beat, health professionals continue to consider CHSP a symptom, despite the fact that online comments show that some people only chew and spit, and do not appear to also have anorexia or bulimia.
One day, I just thought, 'What if I just don’t swallow my food?'
"I was bulimic for five or six years," Hannah*, who had previously posted about her chewing and spitting problem on Reddit, told me. "One day, I just thought, What if I just don’t swallow my food? The guilt after the act was still there, I was being so wasteful, but I couldn’t really stop doing it. In a vain attempt to make myself feel less wasteful, sometimes I’d collect it and put it outside for the birds. Gross, I know."
Hannah is one of three women who agreed to speak to me about their chewing and spitting when I reached out to them after finding their posts on forums. All three women are young (between 18 and 24), suffer from body image issues, and wish to remain anonymous. This desire for anonymity sheds light on one of the most pervasive and crippling aspects of CHSP: the shame.
"When I first had a problem, I was so ashamed that I didn't tell anyone," a 21-year-old intern at a financial institute — who wishes to be identified as L — told me. Like the online commenters mentioned above, L only suffers from CHSP, and does not have any other disordered eating habits.
"It's not something easily recognizable or serious like anorexia or bulimia. To me, it was just a weird and gross habit that I would have to explain to whoever I told," she said.
I can’t recall the last day where I didn’t chew and spit at all. I will constantly walk away from what I’m doing to do this. Some days, it could take up hours of my time.
"I would absolutely 100% consider it an addiction," said Frances*, a full-time student in the U.S., who has been chewing and spitting for two years. "I can’t recall the last day where I didn’t chew and spit at all. I will constantly walk away from what I’m doing to do this. Some days, it could take up hours of my time."
As for Dr. Kinmond, she said that there is potential in any behavior for addiction, and she noted that CHSP could be considered a form of self-harm. But scientifically, there is an additional argument for CHSP being addictive. Writing on her personal blog, molecular neuroscientist and science writer Shelly Fan explained one study that found chewing and spitting causes an increase in ghrelin, a hormone that promotes hunger. "It is conceivable that chew-and-spit may increase hunger levels in AN [anorexia nervosa] patients, leading to feelings of a lack of control over eating," she wrote. "This may counteract the patients’ rigid control over food intake and promote more chewing and spitting (or binge eating), resulting in a downward spiral."
Similarly, CHSP can also become a compulsion for an individual suffering from OCD. Dr. Kimberley Quinlan, a licensed California-based therapist who specializes in co-existing eating and anxiety disorders, explained how to tell the difference.
"The content of the obsessions is the most clinically correct way to differentiate between the two," she told me over email. "If someone is compulsively chewing and spitting to control or reduce a fear related to body weight or body image, it is almost always an eating disorder." She went on to say that, for those with OCD, chewing and spitting is unrelated to body size, but is instead done for a variety of reasons, such as an attempt to neutralize intrusive thoughts or a fear of food making the person unwell. "The behaviors might look very similar, but the fear behind them is very different," she said.
Addiction and compulsion aren’t the only harmful side effects of CHSP. Most of the women I talked to "figured out" chewing and spitting on their own (one got the idea from the MTV comedy show Girl Code and another from an episode of Sex and the City), because they erroneously assumed that it would allow them to taste and enjoy food without any "negative" consequences.
And physical effects aren't uncommon, either. Hannah said that CHSP sessions made her vision "go white" and her body feel weak and lightheaded. Other side effects reported by those I talked to include stomach and mouth ulcers, swelling of the jaw from the repeated chewing motion, and a build-up of gas.
I get extremely anxious when I go out with other people, because I know I can’t get away with this behavior.
But the thing is, until we're able to figure out where CHSP falls on the diagnosis spectrum, there's not much we can do to help people who suffer from CHSP behavior.
"If CHSP is not included in the DSM, then this may make it easier for some people to come forward, as they will not feel they are psychiatrically ill or being labeled," Dr. Kinmond said. "However, in order to receive the relevant treatment, it may be helpful to have a recognized label."
She added, "Arguably, there may be people engaging in this behavior who either do not see it as a problem, or do see it as a problem but do not know where to go for help."
Ultimately, if people are to be able to seek treatment for CHSP, we need to assess our acknowledgement of it as a disorder — which means we need to start talking about it more.
*Names have been changed as interviewees wished to stay anonymous.
If you are struggling with an eating disorder and are in need of support, please call the National Eating Disorders Association Helpline at 1-800-931-2237. For a 24-hour crisis line, text “NEDA” to 741741.