What causes anorexia nervosa, the terrible mental illness whose victims (mostly young women) starve themselves, sometimes to death? To many observers, the answer is clear: Hollywood, Madison Avenue, and Seventh Avenue. Film and television actresses are impossibly thin; advertisers hawk an endless profusion of diet products and banish average-looking people from their commercials; the fashion industry recruits tall, scrawny teenagers as its models and tosses them aside if they become too womanly. When girls and young women are constantly bombarded with thin-is-beautiful messages, is it any wonder that some of them overreact?
Christy Greenleaf, assistant professor of kinesiology, health promotion, and recreation at the University of North Texas, doesn’t think so. She has written: “Girls and women, in our society, are socialized to value physical appearance and an ultra-thin beauty that rarely occurs naturally and to pursue that ultra-thin physique at any cost. Research demonstrates that poor body image and disordered eating attitudes are associated with internalizing the mediated (i.e., commodified, airbrushed) bodies that dominate the fashion industry.” The narrative is a plausible one, and it fits a familiar template: Big business uses mass media to destroy consumers’ health by creating harmful desires. Yet there are large parts of it that don’t hold up.
In the first place, anorexia is not in any way an artifact of our modern, weight-obsessed society. Thomas Hobbes wrote about it in the 1680s. A 1987 study showed that anorexia in the United States increased throughout the 19th century and peaked around 1900, when chorus girls were voluptuous and the boyish flapper look was still two decades away. A similar historical pattern has been found for eating disorders in France. Some interplay of genetic and environmental factors may be at work in these cases, or they may have resulted from the common pattern in medicine of certain diagnoses’ rising and falling in popularity. But it’s clear that none of these outbreaks can be attributed to the late-20th- and early-21st-century emphasis on skinniness.
There are plenty of other examples. The medical historian I. S. L. Loudon has identified chlorosis, the 19th-century “virgin’s disease,” with anorexia and shown that diagnoses of it reached “epidemic proportions” in Victorian England before disappearing completely between 1900 and 1920. A pair of Dutch historians have traced the practice of severe self-starvation all the way back to the early Christians and described the various explanations that were offered for it over the centuries (holiness, witchcraft, demonic possession, miracles, various nervous or emotional disturbances) before a newly scientific medical profession defined it as an illness in the mid-19th century.
All these statistics must be taken as rough indications only. Eating-disorder rates, like those for most psychiatric illnesses, are notoriously slippery, since the conditions are so hard to pin down. Journalists sometimes say that anorexia rates have been increasing for decades, as Americans’ lives have become more media-saturated; one source reports that anorexia in young adult females has tripled over the past 40 years. This is a case of the common phenomenon in which growing awareness of a condition leads to increased diagnosis of it, even when there is no real increase in its prevalence. Researchers who have carefully studied the data conclude that there has been no significant change in the rate of anorexia in America since at least the mid-20th century.
Moreover, while it’s tempting to blame America’s appearance-obsessed culture for the plight of its self-starving daughters, anorexia is a global phenomenon. A 2001 article reviewed the extensive literature on eating disorders among residents of Europe, Asia, Africa, the Middle East, and Australia. In some regions, the reported rates of anorexia were several times that of the United States (though, as above, such figures must be taken with caution). In a case of political correctness attacking itself, one researcher says those who attribute anorexia to media sexism are being ethnocentric: “The biomedical definition of anorexia nervosa emphasizes fat-phobia. . . . However, evidence exists that suggests anorexia nervosa can exist without the Western fear of fatness and that this culturally biased view of anorexia nervosa may obscure health care professionals’ understanding of a patient’s own cultural reasons for self-starvation.”
If it isn’t skinny models, what’s the cause? In the last dozen years or so, scientists have linked anorexia to many different physiological conditions: high levels of estrogen in the womb; low levels of serotonin in the brain; a genetic mutation; overactivity by dopamine receptors; a general tendency toward anxiety and obsessionality; high age at menarche; elevated amounts of a mysterious peptide called CART; autism (which is underdiagnosed in girls, perhaps because it sometimes manifests itself in the form of eating disorders); premature birth or other birth complications; irregular activity in the insular cortex of the brain; post-traumatic stress disorder; an autoimmune disorder affecting the hypothalamus and pituitary gland; variations in the structure of the anterior ventral striatum (the brain region responsible for emotional responses); and even being born in June (seriously — one theory is that a winter-type disease in the mother at a certain vulnerable point during the pregnancy is responsible). Some of these causes may overlap with one another, but biomedical researchers are virtually unanimous that anorexia has physical roots, though the mechanism remains poorly understood.
#page# Might these physiological factors be what makes one susceptible to anorexia, but cultural images are what sets it off? Walter Kaye, a psychiatry professor at UC–San Diego, has suggested such a mechanism: “Less than half of 1 percent of all women develop anorexia nervosa, which indicates to us that societal pressure alone isn’t enough to cause someone to develop this disease. Our research has found that genes seem to play a substantial role in determining who is vulnerable to developing an eating disorder. However, the societal pressure isn’t irrelevant; it may be the environmental trigger that releases a person’s genetic risk.”
Maybe, but probably not. As noted above, anorexia has flourished in many times and places with no mass media and no ideal of thinness. Anorexia could be just another manifestation of self-destructiveness, like slashing one’s wrists. It could stem from some cause unrelated to body image, such as disgust with the processes of digestion and elimination (as well as menstruation, which often ceases in long-term anorexics). Psychiatrists believe that many anorexic women want to reverse the effects of puberty, such as breasts and hips, and while most of today’s film and television sex symbols are indeed slender, they rarely lack for breasts and hips.
Despite the uncertain connection, some observers still think the media need to change their act. Professor Greenleaf has suggested: “A potentially healthier approach is to include [in advertising] a variety of body shapes and sizes (as opposed to idealizing only one physique). Healthy bodies come in all shapes and sizes — and health is what should be valued, which may not fit with the fashion industry’s emphasis on ultra-thin beauty.”
The suggestion is not outlandish. Many advertisers and fashion magazines have, in fact, tried using “a variety of body shapes and sizes” among their models — once. It makes a decent publicity gimmick, but there’s a reason they always go back to slender models: Clothes look better on them. (Also, it usually isn’t practical to custom-sew garments for individual models, so clothing samples are made for a standard size 6.) And for some reason, viewers of films and television, male and female, tend to like beautiful actresses rather than healthy ones — not to mention the common observation that “the camera adds ten pounds.”
If increasing the labor pool for models and actresses by including heftier ones yielded equally good results, the industries in question would have done it long ago. Why deal with a bunch of stuck-up teenagers if you don’t have to? If media and fashion conglomerates really do dictate our image of the ideal female, why don’t they manipulate us into going crazy for plumpish housewives instead? And even if it’s true that media images make some people weight-conscious, the benefits must easily exceed the costs, since obesity is a much greater problem in America than anorexia.
Nonetheless, some lawmakers are calling for bans on skinny models. Madrid and Milan have prohibited those with a body-mass index lower than 18 from their fashion shows. (Body-mass index is the weight in kilograms divided by the square of the height in meters. A BMI of 18 is considered the low end of the normal range, but you wouldn’t expect models as a group to have “normal” physiques, any more than you would expect it from football players.) Similar bans have been proposed in Quebec, London, New York City, New York State, and France’s national assembly. The main goal of these bills, which began to be introduced after several models starved themselves to death, is supposedly to reduce anorexia within the industry, though proponents always invoke the baleful effects that waif-like models have on society as a whole. Yet this assumes that self-starvation is a willful choice that anorexics will abandon if given the proper incentive, when in fact it is a mental illness that for centuries has proven stubbornly impervious to rational arguments.
Anorexia is a dreadful disease, and still poorly understood. If the growing scientific knowledge about it can be pieced together, we may eventually learn to identify, prevent, treat, and possibly cure it. But political activists do not help its sufferers when they oversimplify a complicated condition and blame it on their stock assortment of evil forces in American society.