By Daniela Ferreira Araújo Silva, Endangered Bodies Brazil team member

Last week I saw the trailer for To The Bone, a movie just released by Netflix. It is supposed to be a sensitive and deep portrayal of the struggles of a young woman with anorexia and her journey through treatment. However, the almost two-and-a-half minute trailer couldn't be more upsetting: a cliché and somewhat sensationalized depiction of what anorexia supposedly looks like unravels with scene after scene violating almost every single National Eating Disorder Association's guideline for responsible media coverage of eating disorders. It features obsessive calorie counting, graphic depictions of symptomatic behaviors concerning eating and exercising, and images of the main character’s severely emaciated body.

Being an eating disorders researcher and activist since 2001, and a bulimia survivor, I’ve been concerned not only with the lack of substantiated knowledge about eating disorders both among health professionals and the wider public, but also with the media. Media content can be problematic when it promotes an excessively thin beauty standard for women, in addition to the usually sensationalist tone given to the subject of eating disorders. 

The movie and its trailer have stirred things up in the online eating disorder community, especially with regard to its heavy marketing emphasizing the possible benefits of the film in raising awareness on the subject. However, my account as well as those of several others, stresses another aspect: its risks.

Prevention of eating disorders is not best carried out by listing the typical disordered behaviors, since it tends to cause more harm than good, as research by Mann et al. (1997) and Carter et al. (1997) noted more than two decades ago. Instead, the most successful programs are based on body acceptance and cognitive dissonance interventions regarding beauty standards (e.g. Stice, Shaw & Marti, 2007; Shaw, Stice & Becker, 2009).

One of the reasons for that may be the fact that eating disorders, anorexia in particular, are egosyntonic. This means that the person identifies with the symptomatic, disordered behaviors, not considering them problematic. It is usually the opposite: the person with the eating disorder is convinced that they are necessary, and perhaps even the best way to care for oneself under the circumstances. Thus, it is no surprise that when faced with the extreme thinness of the main character in films like To The Bone, people suffering from eating disorders may feel compelled to dedicate even more effort to losing weight. This is particularly complicated in a culture that values thinness at all costs, in which women of all sizes feel bad about their bodies after looking at women’s magazines (Hamilton, Mintz and Kashubeck-West, 2007) and where 47% of teenage girls who took part in a study stated they wanted to lose weight and were motivated by pictures in magazines (Field et al, 1999).

Trying to fight eating disorders with images such as those featured in this movie trailer is equivalent to fighting alcoholism by showing people drinking. The appeal of the depicted behaviors will be far greater than any warning about their risks or harm.

Some of the things I've learned later about the film have made me even more upset: the lead actress, Lily Collins, who has a personal eating disorder history, had to lose a significant amount of weight for the role. Despite recognizing strong scientific evidence that entering into an energy deficit and/or losing weight can make people with a history of anorexia much more prone to relapse, Project Heal, an eating disorders recovery support agency, still chose to support the film, claiming that the filmmakers' "creative decision" about the weight loss was made before the organization joined the project. On their own website, the agency recommends that people who struggle with eating disorders should exercise caution in deciding to watch the movie. In fact, stills of the film featuring the main character have already been reported to be used as thinspiration.

How is it possible that despite being aware of all the risks the people involved still chose to produce and support this movie in this particular way?

Apparently, there is a recent trend that seems to believe that there is no such thing as bad press. The recent case of yet another Netflix series about suicide, featuring several elements that are known to increase the risk of suicidal behavior is remarkably similar. As it is the case with To The Bone, the series also had a partnership with a suicide prevention organization. Some argue that the benefits of the possible widespread awareness may be greater than the harm. But it could be possible to make a movie about the subject without the harmful details, emphasizing other aspects: such harm is not a "necessary side effect". Perhaps when lacking the shock and sensationalized elements, and even the "bad press" and the discussion about it, it might not have the same audience success.

Due to my line of work, the logarithm-oriented advertisements based on my web habits are predominantly devoted to the diet industry. One of these advertisements simulates a news piece, and its fake headline mentions the "dangerous weight loss" of a somewhat famous TV actor. The very existence of such ads is proof that mentioning "dangerous weight loss" serves not just as clickbait, but also helps to sell diet pills.

Instead, I would argue that some forms of harm should be avoided at all costs. My bulimia started on the afternoon I watched a film about the disorder on TV. Perhaps, if I hadn't seen the movie, I would have eventually developed bulimia anyway. I will never know. That said, I would like that other people, who are currently experiencing similar vulnerabilities I was facing at the time, would be given the opportunity I didn't get. 

* * * 

References:

Carter JC, Stewart DA, Dunn VJ, Fairburn CG. (1997) Primary prevention of eating disorders: might it do more harm than good? Int J Eat Disord. 1997 Sep;22(2):167-72.

Field AE, Cheung L, Wolf AM, Herzog DB, Gortmaker SL, Colditz GA. (1999). Exposure to the Mass Media and Weight Concerns Among Girls. Pediatrics. March 1999, VOLUME 103 / ISSUE 3.

Hamilton EA, Mintz L, Kashubeck-West S. (2007). Predictors of Media Effects on Body Dissatisfaction in European American Women. Sex Roles, 2007, Volume 56, Number 5-6, Page 397.

Mann T, Nolen-Hoeksema S,,Huang K, Burgard D, Wright A, Hanson K. (1997) Are two interventions worse than none? Joint primary and secondary prevention of eating disorders in college females. Health Psychology, Vol 16(3), May 1997, 215-225. http://dx.doi.org/10.1037/0278-6133.16.3.215.

Shaw H, Stice E, Becker CB. (2009) Preventing eating disorders. Child Adolesc Psychiatr Clin N Am. 2009 January ; 18(1): 199–207. doi:10.1016/j.chc.2008.07.012.

Stice, E; Shaw H; Marti, CN. A meta-analytic review of eating disorder prevention programs: encouraging findings. Annu Rev Clin Psychol. 2007;3:207-31. DOI:10.1146/annurev.clinpsy.3.022806.091447.