The recent BBC report on the toxic culture of body-shaming in some of UK’s most elite ballet schools is heartbreaking to read. (Ex-dancers describe body-shaming at top ballet schools). As a parent of a competitive dancer myself, I feel deeply for the affected students and their parents. As a physician specialising in Performing Arts Medicine, I am well aware of the broader issues in dance medicine surrounding health and wellbeing of dancers and elite performing artists.
Relative Energy Deficiency in Sport (RED-S)
Health concerns like mental health, eating disorders, menstruation irregularities and musculoskeletal injuries among high-performing teens in dance and sports are problems that I frequently see in my practice. Many dancers suffer from Relative Energy Deficiency in Sport (RED-S), formerly known as the Female Athlete Triad. The triad of low energy availability with or without an eating disorder, low bone mass (osteoporosis) and menstrual disturbance was first coined by the American College of Sports Medicine over 30 years ago after experts identified this pattern among young female athletes, especially those involved in sports that emphasize aesthetics or leanness such as ballet, gymnastics, running and cycling.
The energy deficiency is an imbalance between dietary energy intake and the energy expenditure required to support health, growth, activities of daily living and sporting activities. More recently it has been recognised that the phenomenon is not simply a triad, but rather a syndrome now known as RED-S which involves many aspects of physiological function including metabolic rate, menstrual function, bone health, immunity, cardiovascular and psychological health. In addition, RED-S also affects men.
Despite the serious and wide-ranging health complications that can arise from RED-S, research has shown that awareness of RED-S is low among physicians across disciplines, psychiatrists, physical therapists as well as dance and sports educators.
Dancers are known to be 3 times more likely to suffer from eating disorders than the general population. Eating disorders are strongly linked to personality factors such low self-esteem, perfectionism and high self-standards. These personality traits are common among high-achieving performing artists and athletes, and also manifest as anxiety, depression, obsessive-compulsivity, burn-out, and in performing artists, performance anxiety.
In my childhood I trained many years in piano and ballet, and the mantra “practice makes perfect” was drilled into my subconscious. Striving for perfection is natural to performing artists in the pursuit of their artistic goals. Perfectionistic individuals have self-imposed high standards that motivate them to greater heights, but can also cause significant dysfunction and distress. And herein lies the negative side of perfectionism – maladaptive or unhealthy perfectionism, where there are negative reactions to mistakes, dissatisfaction with performance, lower confidence and self-esteem, and greater anxiety and psychological distress (Stoeber and Otto 2006). Performing artists are constantly exposed to critique – both the outer critic (the audience, judges, teachers, examiners, their own parents, social media) and the inner critic (themselves) – undoubtedly a major source of stress which is not easy to manage.
Parenting and support
As parents, teachers and coaches, we need to be aware of these pitfalls and be able to support our kids in positive and healthy strivings for excellence, rather than the quest for perfection. Encourage your kids in ways of healthy practice habits; speak to their tutor/coach to understand these better. Pay firm attention to healthy lifestyle habits – nutrition, general exercise, sleep, mental wellbeing and social connections. Help them set realistic goals and remind them of the big picture and long-term targets. If they need professional help, speak to a counsellor, therapist or your family doctor. Before you say to them ‘practice makes perfect’ – think again.
Dr June Tan Sheren, MBBS (Singapore), MMed Family Medicine (Singapore), MSc Performing Arts Medicine (UK), Family Physician, Performing Arts Medicine Physician. Dr June is based at Osler Health Raffles Hotel Arcade clinic. Dr June is passionate about supporting young artists’ mental and physical health and is one of the few Performing Arts Medicine Physicians in Singapore.