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Ana & Mia: The Online World of Anorexia and Bulimia

I Introduction

Imagine this: a twelve year old girl struggling with her weight, feeling insecure and alone goes online to find a better diet -- something that will help her lose weight faster before she has to go into Grade 7. She often wonders if she has an eating disorder, not fully comprehending what that means. She goes to a search engine and types in "eating disorders." It pulls up 650,000 entries. Confused, she narrows her search down to "anorexia" -- 417,000 entries. She clicks haphazardly on one entry and it takes her to a page where she sees a photograph of an emaciated model and beside it the "0 Thin Commandments."

1. If you aren't thin, then you aren't attractive.

2. Being thin is more important than being healthy.

3. You must buy clothes, cut your hair, take laxatives, starve yourself, do anything to make yourself look thinner.

4. Thou shall not eat without feeling guilty.

5. Thou shall not eat fattening food without punishing oneself afterward.

6. Thou shall count calories and restrict intake accordingly.

7. What the scale says is the most important thing.

8. Losing weight is good; gaining weight is bad.

9. You can never be too thin.

10. Being thin and not eating are signs of true willpower and success.

She has stumbled upon a pro-anorexia website.

It seems unfathomable: a movement that promotes and encourages anorexia nervosa -- a devastating eating disorder that claims the lives of thousands of women each year. Yet the existence of such a movement on the internet was exactly what health professionals were forced to acknowledge last summer when the issue first came to light." Hundreds of websites describe anorexia as a way of life, a chosen lifestyle, and refer to these potentially deadly disorders by the affectionate pet names "Ana" (anorexia) and "Mia" (bulimia). With names like "Dying to be Thin," "Anorexic Nation" and "Stick Figures" these are more than just static websites. They are fully developed web based communities.

II Background

No one knows for sure how or when this movement began. Some young women claim that they've known of sites like these for over 4 years. Yet it was only during the summer of 2001 that the media found this underground world and exposed it to the general public and health professionals alike. There were articles in major newspapers and clips on the news; it shocked the health professional world and sent chills through the public. Organizations and associations struggled to figure out how to respond and react to the situation. One response was to petition the servers that were hosting these websites to shut them down. At the end of July, Yahoo decided to pull the plug on some of the websites citing that they violated their user agreement to not post "harmful, threatening or abusive" material, and in the following months several other servers followed suit. Many of the websites that existed six months ago are no longer in operation but some of them have simply changed servers and URLs, added password protection and gone further underground.

A few short months later the issue is still a hot and widely debated topic but the hype in the mainstream media has died down. Now the health profession must take this opportunity to thoroughly contemplate the issues and work towards a long term, strategic solution.

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III What is on a pro-anorexia website?

The pro-anorexia movement is comprised of websites, chat rooms and electronic message and discussion boards. The websites are largely created and hosted by girls and women who are struggling with an eating disorder. Some have been diagnosed and were in treatment that was not successful while others have never been diagnosed. Some websites are being run by girls as young as fourteen and in case a young girl's site remained static but online after friends and family were unable to access the site following her death from her eating disorder.

These websites contain dangerous and incorrect medical and nutritional information about restrictive eating, metabolism, bingeing and laxatives. Some of the more common inclusions on pro-eating disorder websites are

* Journals -- filled with descriptive and often gory details of the lives of girls and women who are struggling to deal with very serious eating disorders, some who are also plagued by depression, anxiety, self-injury, abuse and a host of other issues.

* Triggers -- pictures that are intended to inspire visitors to stay thin or become thinner (they are called "thinspiration"), pictures of thin and often emaciated supermodels like Kate Moss and actresses like Gwenyth Paltrow, Calista Flockhart and Lara Flynn Boyle. Sometimes these pictures are modified to make the woman look thinner and sicklier but often there is no need to distort the pictures. Some sites even show pictures of patients with anorexia from hospital beds or from textbooks.

* Reverse triggers -- pictures of fat women are intended to remind visitors that if they start eating they'll end up the same way and that they "never want to end up looking like that."

* Quotes -- intended to inspire visitors to restrict their eating behaviours and maintain their dangerously low weights. "If you eat over 500 calories, vomit, use laxatives or fast the next day." "A good anorexic is one who does not die."

* Tips & Tricks -- on how to vomit more effectively, binge secretly, trick doctors during weigh-ins, use laxatives, what to eat that has little or no calories, burn extra calories, use vegetarianism as an excuse, etc.

* Message Boards & Chat Rooms -- where girls and women with eating disorders gather to share their struggles, their stories, their beliefs, their reluctance to consider treatment as an option, and to share tips on being a "good anorexic."

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IV Why do these websites exist?

It's an obvious question to ask -- why would anyone create such a disturbing website environment and why would someone torment themselves by viewing the contents? It's actually quite understandable when you consider the psychological and physiological affects of the disorder they are struggling with. When the brain is starved for nourishment it simply doesn't function effectively.

The movement seems to make sense to these girls and women. They feel isolated and scared and most of them would acknowledge that they are ill, yet they can't imagine their life without the eating disorder. In their minds, recovery means becoming fat and that simply is not an option for them. These sites provide these individuals with a sense of community that is supportive, understanding and non-judgmental. They look to each other to validate their behaviours and feelings because they know that they are sick but they are too scared to give up "Ana." These women do not want to die, they want to be in control and that means using thinness as the visible means of this willpower.

Many of the women admit that they wouldn't wish anorexia on their worst enemy and don't wish to recruit new members, yet now that this is their life they are holding on to it because it has become their identity and a structure for their lives.

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V What are the risks?

Despite the support and understanding that these women get from each other they also encourage each other to remain sick. They encourage each other to, ironically, "stay strong" and not to let "them" (parents or professionals) take "Ana" away from them.

The messages on these websites are incredibly ambivalent, which coincides with how the women feel about their own eating disorder. On one hand you have a statement indicating that it is not their intention to recruit new members and on the other hand you will see tips on "how to become anorexic."

Many of these sites have disclaimers on the home pages warning visitors about the nature of the content. They post warnings such as some viewers may consider the materials offensive, if you don't want to be triggered do not enter, and that their intentions are not to lure anyone into the world of anorexia. However, these disclaimers will not help a young girl who wants to be triggered and shown the fastest and easiest way to lose weight.

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VI Dissension and Controversy

The issues around this movement are complex and controversy is brewing. Even among advocates of the pro-eating disorder movement, there is some discord around the meaning of pro-anorexia. Some women refer to themselves as "pro-anorexic" because they support the web environments that provide them with a venue to express themselves and be heard, but denounce the sites that glamorize and celebrate the disorder. Others more openly advocate anorexia as an acceptable and even admirable lifestyle.

Professionals are also facing a quandary and have varying opinions on how to deal with the proliferation of these sites. Some professionals believe that these sites must be shut down in order to protect the vulnerable and continue to encourage the companies hosting these sites to remove them.

However, many professionals question the effectiveness of this approach, wondering if it promotes further alienation and discourages women from seeking treatment. The fear is that such a strong reaction may push the movement further underground and make it more dangerous and defiant. This seems a valid concern given that the pro-anorexia community is very angry at the media, which has labeled them as uncaring, insensitive and evil and at the professional world that is trying to shut them down. They see it as a personal attack and feel as if they are being silenced and ignored.

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VII Next Steps

It would be a superficial solution to blame the women who have created these sites and simply force them all to shut down. But, these women are not uncaring, insensitive or evil. They are suffering from a debilitating disorder that has affected their logic and their emotions. And we've seen that the sites that are forced to shut down will just pop up somewhere else and that new ones are constantly being created. Yet at the same time we are forced to acknowledge the potentially dangerous consequences of vulnerable individuals coming across these sites. Young girls and women are learning how to slowly kill themselves. We need to focus on the big picture and figure out how to deal with this issue over the long-term. The internet is here to stay and it is likely that the movement will continue to grow as long as it continues to serve a purpose to its members. We need to continue to focus on the bigger evils that exist by challenging the diet industry and the cultural messages that dictate thinness as the only acceptable size and the only means to self-efficacy and self-esteem.

Health professionals must band together and find answers to the following questions:

* How do we protect vulnerable individuals from the dangerous effects of these websites without alienating a whole community who are in need?

* Does it make sense to shut the sites down or does it create a greater divide between professionals and sufferers?

* Who is morally and legally responsible if a child were to die as a result of following the directions on one or more of these sites?

* Is it true that these websites actually scare some women into treatment and recovery?

* Is the support these women get from each other outweighed by the constant messages to stay sick?

* How do we more effectively counteract these negative, unhealthy environments - what kind of positive online and offline environments can we create to provide individuals with more options for support and sharing and opportunities to build resilience?