How Pro-Anorexia Websites Exacerbate the Eating Disorder Epidemic

In 2010, Alex Chernik told his younger sister Natalya, "You got fat." In most situations, that sort of thing would have ended there, a little teasing between siblings. Natalya and Alex were close; though not biologically related, they were both adopted from Russia by the same family living in bucolic Cheshire, Connecticut, and they teased each other all the time. But that particular jab was to be the last thing Alex said to his little sister. That year, when Natalya was 15, Alex killed himself. He was 18.

And so the words quickly took on a disproportionate significance for Natalya. "My mentality was, I want to make him happy," she says. "I'm gonna lose weight." Natalya began restricting her calories, poring over nutrition facts on labels, and eventually what had been a healthy, disciplined diet turned into something that looked like starvation. She started visiting and then following Tumblr pages fostering a pro-ana lifestyle—a portmanteau that refers to anything that promotes or encourages anorexia. If she started to feel sick or hungry, she would visit blogs that flaunted lines like Kate Moss's infamous mantra "Nothing tastes as good as skinny feels." They motivated her, reminding her that she didn't have to eat.

Three months after her brother's death, her parents were taking her to mandatory weekly weigh-ins at the doctor's office, where she would typically come in at around 90 pounds. She was eventually hospitalized, and doctors performed an endoscopy to examine her digestive tract. When she came to after the anesthesia wore off, a feeding tube was in her mouth. She immediately started choking. She still remembers the words the doctor told her after pulling the tube out: "There is nothing physically wrong with you. You have anorexia."

Anorexia is by many estimates the most lethal of all mental disorders. Studies show that those with anorexia are over five times more likely to die than the normal population. For comparison, individuals suffering from schizophrenia (which has a similar prevalence) are about two to three times as likely. Even more alarming, 15- to 34-year-old women with anorexia nervosa are 18 times more likely to die by suicide, compared with the general population of females that age. And it's likely worse than we know, since we don't have a national database on anorexia mortality. This is largely because death certificates rarely list it as a cause of death—girls who die from anorexia are more likely to have officially died due to heart failure, cardiac arrhythmia, respiratory collapse and, frequently, suicide.

Despite such grim statistics, until recently anorexia nervosa has remained one of the least discussed mental illnesses. Eating disorder research is badly underfunded; the National Institutes of Health allocates just $1.20 in research dollars per eating disorder patient, compared with $159 per patient with schizophrenia. In the past few years, though, anorexia has begun garnering more attention because of two internet subcultures. In the early 2010s, hashtags like "Thinspiration" and "Thinspo" were gaining notoriety on social media as supposed motivational tools, but they were much more likely to propagate body image problems.

Concurrently, a less mainstream but potentially more pernicious niche was growing: Pro-ana and pro-mia (short for pro-bulimia) websites, blogs and forums, which had long offered a more explicit entry point into the world of extreme weight loss, spread. In these dark, private and propagating spaces, anorexia was becoming a lifestyle full of its own nuances and argot, just like those found among online communities of cosplayers or running aficionados.

Once castigated as the equivalent of "putting a loaded gun in the hands of someone suicidal," as Holly Hoff, then-program director of the National Eating Disorders Association, described them in 2003, the forums are now viewed by some as among the only platforms available for sufferers to candidly discuss anorexia as a mental health problem. In some cases, that might be true. The difficulty, though, is that it can be impossible to distinguish between sites that are refuges from the ravages of anorexia and those that are bastions of recruitment for it.

They Barely Fed Me

In the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, the criteria for anorexia nervosa includes significantly low body weight, intense fear of becoming fat and a disturbance in the way in which one's body weight or shape is experienced. None of that explains how someone develops the disorder, though some experts are starting to gain some understanding of how it emerges.

Angela Guarda, director of the Eating Disorders Program at Johns Hopkins University, explains that there are three levels of causality in anorexia. The first, predisposing factors, primarily refers to genetic predisposition and family history. "If you have a family member who has anorexia, you have somewhere around tenfold the risk of developing it," she says. Next are precipitating factors—basically a triggering moment, which could be going on a diet, starting a running routine or even, some clinicians think, the onset of estrogen production in the female body during puberty. Last are maintaining factors. These are in some ways the hardest to understand but arguably the most critical to successful treatment. Maintaining factors include beliefs about food, increasing obsession with body image and, perhaps most important, nearly intractable changes to the brain.

"I'm aware of disruptions in neuro-functioning among people with anorexia," says Suman Ambwani, a psychology professor at Dickinson College. "When you've been starving your brain for an extended period of time, that can have very significant and real effects on how your brain is functioning."

Prolonged brain starvation comes with significant cognitive deterioration, including poor judgment, concentration problems and rigid thinking. This severely compromised intellectual state makes it more difficult to recognize and break negative patterns, meaning those with anorexia are woefully ill-equipped to retrain their brain to escape the vicious cycles.

Pro-ana websites, it turns out, may have an impact alarmingly similar to those maintaining physiological factors that tighten anorexia's grip. Emma Bond, an associate professor at England's University Campus Suffolk who did extensive research on pro-eating disorder websites for her 2012 report titled "Virtually Anorexic—Where's the Harm?," describes a chain reaction that occurs when sufferers begin feeling isolated by their illness and then discover the websites. "The more socially isolated they become, the more they actually use the sites, and the more depressed they become, and the more that becomes normalized."

What distinguishes anorexia from almost all other mental disorders is the language and repertoire of illusions that entrench and romanticize it. Many pro-ana blogs and websites depict anorexia as an act of extraordinary willpower or a chance for radical self-actualization. Very rarely will someone in the throes of a crippling depressive episode vigorously defend its virtues or the thrill it gives her. But anorexics often see their disorder as the key to unlocking happiness and are privately ecstatic over their emaciated figures, growling stomachs and protruding bones.

Almost all of the young women I spoke with (the vast majority of those affected by anorexia are females in their teens and 20s) cited at least one other major co-occurring problem, ranging from substance abuse, depression and suicidality to post-traumatic stress disorder and anxiety. For some of them, anorexia was (or is) a byproduct of a primary disorder. One girl spent much of her childhood shuttled among abusive foster families, one of which, she says, "barely fed me," causing her to feel guilty about eating.

For others, says Erin Kleifield, director of the Eating Disorders Program at Silver Hill Hospital in New Canaan, Connecticut, an eating disorder is developed to escape from the primary problem, a way to regain the control and emotional satisfaction relinquished to the depression or anxiety. "The eating disorder becomes a way of solving that problem. So they're very depressed, they have low self-esteem, feel disconnected, don't feel good about themselves. 'This is my answer. This is a way I can feel better about myself.'"

Natalya's anorexia, of course, was a way of dealing with the feelings brought on by her brother's tragic death. Even after the revelation in the hospital blindsided Natalya and then stripped her of her denial, the anorexia still had her in its throes. She endured multiple hospital admissions and couldn't get her weight above 90 pounds. "It consumed my entire life. Every second of every day, I was thinking about food and how little I could eat and still live." Natalya recalls feeling that her life was "so out of control" and that her body was the only thing she could regulate. Pro-ana blogs and Tumblr pages were "definitely a negative influence on me," she says. Whenever she began questioning her unhealthy behavior, she visited pro-ana sites to validate it.

These sorts of behaviors have unfurled exponentially in the social media age. Whereas in 2010 all young people had was Facebook and MySpace, today the language, motifs and compulsions that accompany the disorder can be made explicit on blogs, forums and Instagram posts. A pathological attitude toward a pathological behavior—one of anorexia's defining features—is now accessible 24/7 on hundreds of sites.

Many researchers are finding these pro-ana and pro-eating disorder (pro-ED) websites and social media to be inimical to recovery. "There is evidence of harm. I don't think that's even debatable," says Kristin von Ranson, a psychology professor at the University of Calgary. A systematic review she published in 2010 looked at 27 previous studies on pro-ED websites and found several recurring risks, including reinforcement of disordered eating and resistance to recovery.

Leah Boepple, a University of South Florida doctoral student whose 2016 analysis of images on thinspiration websites was published in the International Journal of Eating Disorders, concurs. "I think this content has the potential to be both a precipitating and a maintaining factor," she says. "I think research will eventually suggest that [pro-ED sites] do have the ability to maintain anorexia symptoms."

A 2010 study published in the European Eating Disorders Review found that after female college students with a normal body mass index were exposed to pro-ana websites for just 1.5 hours, their food intake decreased the following week by almost 2,500 calories. Perhaps most worrying is that the study exclusively recruited healthy girls. "Imagine what hours might do for a more vulnerable individual," says David LaPorte, the Indiana University of Pennsylvania psychology professor who co-authored the study.

Many of the girls suffering from eating disorders offer a much different perspective. Hannah (her name has been changed), a 26-year-old from California, describes pro-ED forums as "some of the kindest and most supportive places available to me." Another young woman says the forum she frequents "encourages recovery for those who are ready for it," and if she did choose to get better, she would still browse the forum "because the sense of community is comforting."

As pro-ana sites grow in prominence, there is some evidence that the prevalence of anorexia nervosa is increasing. Hospitalizations for eating disorders increased 24 percent in the U.S. from 1999 to 2009 and nearly doubled in the U.K. from 2010 to 2013. But because of the constantly evolving nature of the web and social media, and the inextricability of other factors that precipitate anorexia, tying a rise in hospitalizations to pro-ana is next to impossible.

Still, it's obvious that for regular visitors of pro-ana websites, the net effect is harmful. "They're finding a subculture that is reinforcing or justifying what they do," Guarda says. "Idealizing it, perhaps, in a way that's dangerous." As Kleifield points out, people suffering from clinical depression or borderline personality disorder do not cultivate a reciprocative relationship with their disease. They do not lyricize it, obsess over it or project fantasy and aspiration onto it. "We don't see pro-depression sites," Kleifield says. "We don't see pro-anxiety sites."