Cover Story
There are two types of skinny girls. The first type is soft and slender and effortless. She comes by her body naturally, eats second helpings of dessert, cracks jokes about her flat chest. She is waiflike but healthy, with shiny hair and shiny skin. If she is short, people call her tiny. If she is tall, they tell her she could be a model.
The second type of skinny girl works hard to be like the first. She used to be overweight, or maybe she only thought she was. But the second type of girl shapes her body through sheer, relentless work. She spends two hours at the gym every day and eats a salad for dinner—with dressing on the side. Often, this second type of skinny girl wants to fool you into believing she is like the first.
Only if you take a close look at her will you notice the difference. Her skin looks sallow, almost papery, and the hair on her arm stands up because she is always cold. Her collarbone juts out farther than it should, and when she wears low-cut shirts, you can see the traces of her ribcage. But these subtle signs are easy to miss, and without them, she appears just like the first.
When I first met Rebecca (not her real name) halfway through her freshman year at Vanderbilt, I knew right away she was a skinny girl, but I didn’t know which kind.
She had somehow found her way into the lobby of my upperclassman dorm and was sitting there on the couch, eating what looked like Rice-a-Roni when I came back from class. We smiled at each other, talked for a few minutes, and then she returned her attention to the textbook open on her lap.
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It turned out Rebecca was dating a friend of a friend. We never became close friends, but had a couple classes together and usually ended up at the same weekend parties. She was tall and pretty, with the sort of natural coloring that other girls spent hours on a tanning bed trying to match. She was a long-distance runner, circling Vanderbilt’s campus up to 12 miles every day, and I thought her thinness came from sheer athleticism.
Rebecca also studied all the time. When she wasn’t studying, she was working—she relied on financial aid and part-time jobs to pay tuition—and when she wasn’t working, she was running. While the rest of us stumbled out of bed at 1 o’clock on a Saturday, Rebecca was already back from a run, showered and dressed. We passed her in the hallway, in pajamas and ponytails, and she smiled and waved and left for her first job as a nanny for a Nashville family. The girl had it together; nothing could bring her down.
So when I saw her two years later—it was Halloween and I had come back to campus for the first time since graduation—I didn’t recognize her. A girl with margarita breath wrapped her arms around me, slurred my name in my ear and told me she had missed me. I missed her too, I said, and then took a step back to see who it was. It was too late; she was already off and hugging someone else. I saw her again a few hours later, heaving into the bushes. That was normal, people told me; these days, Rebecca was always drunk.
I grew up with a hundred Rebeccas, and went to college with a thousand more. In high school, I knew a girl who tried to study while jogging, carrying a heavy textbook instead of a Walkman. She only ate a few hundred calories a day, and could tell you how many grams of fat were in one potato chip. One of my best friends spent time in the hospital, and even after she was “better” she still refused to eat in front of people. It made her feel fat. During her first year of college, Ruthie threw up four to seven times a day, more if she had a test or term paper. Lauren tested herself by seeing how many days she could go without eating. So even at 5-foot-8 and barely over 100 pounds, Rebecca hardly stood out at Vanderbilt. Her size-2 jeans matched all the other single digits that marched around campus.
As recently as a few decades ago, eating disorders seemed exotic. These days, they’ve become so pervasive that Hollywood scriptwriters crack jokes about them. Last fall, FX aired Starved, a short-lived comedy show about an eating-disorder support group. Up to 10 million Americans, most of them women, struggle with anorexia or bulimia—starvation and binging-and-purging disorders, respectively. Millions more suffer from some form of “disordered” eating. And it’s not just America; most industrialized nations have witnessed a sharp increase in these syndromes.
“Eating disorders used to be considered a middle-class white girl disease,” says Reba Sloan, a Nashville dietitian who specializes in eating disorders. “Now they stretch across all sorts of cultural barriers.” The disorders are categorized as mental disorders. They have the highest fatality rate and one of the lowest recovery rates.
Medical professionals are coming to believe that these conditions might be partially genetic, like alcoholism or addiction. They’ve found evidence that people related to victims of eating disorders are more likely to develop the problem themselves—they can even point to specific chromosomes and tell you where it’s most likely to happen.
But there’s little doubt that cultural factors play a major role. A 1998 Harvard Medical School study found that the island of Fiji went from a society in which “going thin”—the Fijian term for weight loss—was a worrisome condition, to one in which half the women referred to themselves as “too fat” within three years of receiving the first television shows from America. The most popular television shows aired in Fiji at the time were Melrose Place and Beverly Hills, 90210.
Personality also matters. According to Sloan, most people with eating disorders are hardworking, intelligent and eager to please, attributes that can cause an otherwise healthy weight-loss regimen to spiral out of control.
Whatever the root cause, experts agree that eating disorders—including obesity—are appearing in ever-younger populations. An 8-year-old anorexic was unheard of 10 years ago. Today, it hardly makes medical professionals bat an eye. “We are starting to see an increase in the number of children who diet,” says Ovidio Bermudez, medical director of the Eating Disorders Program at Laureate Psychiatric Clinic and Hospital in Tulsa, Okla., and the co-founder of the Eating Disorders Coalition of Tennessee. “Children are acting like teenagers at earlier and earlier ages. They are being exposed to adult issues, including body image and weight ideals. They are remarkably easily influenced, and can pick up on the value of physical appearance.”
Rebecca started dieting in fourth grade. She wasn’t overweight, but she remembers feeling bigger than the other girls. She knew she was supposed to be thin, and she assumed people would like her if she were. “I tried losing weight the healthy way, by eating right,” she says. “But it wasn’t fast enough.” Her parents never told her she was fat, but when she started to diet, they didn’t discourage her. With three sisters and one brother, if she pushed away her plate at dinner, someone would come behind her and eat what was left. Rebecca restricted food and counted calories without any real knowledge of what she was doing. She was 10 years old, and everything she ate made her feel guilty.
In ninth grade, Rebecca entered a large public school and hated every minute of it. She learned about anorexia from health class and teen magazines. She was inspired by articles with titles like “I Starved Myself to Death” and “How I Survived My Eating Disorder.” “I made a conscious decision to try it,” she says. “I just decided not to eat.”
But restricting her food intake made Rebecca hungrier, and when she gave in, she went too far. At 14, Rebecca began binging on food and then throwing it up out of guilt. “At first, it was every couple days,” she says. “Then it was every day, then it was a couple times a day.” Rebecca knew that flushing the toilet so many times in a crowded house would arouse suspicion, so she started throwing up into paper cups and storing them in her bedroom until her family had gone to bed.
Rebecca couldn’t stop the cycle. In one year, she lost 30 pounds, an unusual amount for a bulimic. (Bulimia is not usually characterized by extreme weight loss, since a significant number of calories are always digested before they can be purged and most of what is regurgitated is just pulp.) For a teenager who was only slightly overweight at best, the change was drastic.
Rebecca’s parents noticed her weight loss, but their surprise never turned into suspicion. She was still eating, after all, and adolescent weight loss was normal in her family. “We were all fat kids in my family,” she says. “And then we hit puberty and got taller and weren’t fat anymore.”
Rebecca had also become a vegan, in the hopes a healthier diet would stop her binging and purging cycle. “I thought if I ate only vegetables, maybe I wouldn’t want to throw up anymore,” she says. “But then I discovered things like vegan chocolate cake, and the vegetable plan didn’t work anymore.”
When she returned to school after a summer break, she looked older and thinner, and the other girls noticed. She was showered with compliments. Rebecca didn’t feel like the chubby girl anymore. Despite her new popularity, she found herself turning to purging when something went wrong. “If I had a bad grade on a paper or something,” she explains. “Purging sort of desensitizes you from the issue, so when I was done it would suddenly feel like the paper was ages ago. It didn’t matter anymore.”
Rebecca’s purging became more frequent. “If the day was structured and I had a lot to do, I’d probably only throw up three or four times. When I didn’t, when I was bored and left to myself, it would end up being six or seven times, maybe more.” Throwing up made her dehydrated. Her throat hurt. She felt sick all the time. She stopped going out at night.
Rebecca told her parents she was depressed, but refused to say anything about the cups in her bedroom. They sent her to a therapist. Rebecca wanted the therapist to fix her, but refused to disclose her bulimia. It wasn’t even bulimia in her mind, just something she did to keep from getting fat.
“A lot of people refuse to admit they have an eating disorder at first,” Ovidio Bermudez says. “They call it their ‘secret’ or give it a nickname. They think they don’t have a problem, but they know something is wrong because they can’t tell anyone. It’s a mixture of denial and shame.”
Rebecca’s younger sister Molly (not her real name) confronted her about her secret first. They had gone to visit their older sister in Orlando and were standing in her apartment, arguing about where to eat dinner. Rebecca suggested her favorite restaurant, but Molly refused to go. “What’s the point?” she said. “You’re just going to throw it up anyway.” Rebecca said she didn’t know what Molly was talking about. Molly thought she could make her big sister stop. A family friend had just quit smoking, and Molly asked if Rebecca could quit that way—with gum or a patch.
Rebecca eventually admitted the problem to her sister. She even promised, at times, not to throw up when they ate together. But she didn’t always keep her word. “Mostly,” she says, “we just didn’t talk about it.” A few months later, her older sister found a cup of vomit in her room, put two and two together, and told on Rebecca. Her parents confronted her, but she swore she only did it occasionally. She was already going to therapy, she reminded them; this was going to get fixed.
At her high school graduation, Rebecca’s smile looked like all the others. She had been accepted at Vanderbilt University and planned on becoming an English professor. She was young and thin, but not too thin. Not yet.
At Vanderbilt, Rebecca started running to help her stay thin. Everyone looked so slender and perfect; Rebecca found the “Vandy Girl” image intimidating. Vanderbilt girls wore coordinated outfits and full make-up to their 8 a.m. classes. They put on pearls to meet a friend for coffee and wore cocktail dresses to football games. “I’d walk behind them on the way to class,” she remembers, “and I’d think, ‘Why can’t I look like that?’ ”
So she took up running. She thought that if she ran, she would feel good about herself and not have to throw up. But she’d already been purging every day for four years, and a few trips to the rec center weren’t going to kick the habit. She quit being a vegan and gave up cups—you can’t keep vomit in a dorm room—and made the transition to public puking. She followed a strict set of rules that kept her from getting caught. First, check all the stalls for feet before heading into one to purge. Second, time trips to the toilet with other people’s trips to the shower. Last, no obvious purging, except on weekends when people will think you’re drunk. As far as she knows, no one ever caught on.
Rebecca found other girls with eating disorders in college. Some were anorexics, some bulimics, some compulsive exercisers. She even turned in a fellow student, a girl who lived on her hall, for throwing up in the bathroom.
“Susceptibility to eating disorders spikes in junior high, high school and then again in college,” says Nancy Beveridge, a pediatrician at the Green Hills Children’s Clinic. The image-conscious atmosphere at most schools, combined with academic pressure and the freedom to form their own eating habits, causes over one-third of female college students to develop some form of disordered eating: refusal to eat certain foods, restrictive dieting, laxative abuse. The prevalence of such practices at a place like Vanderbilt makes it even easier for more serious cases, such as Rebecca’s, to be overlooked.
Not even her long-term boyfriend, Benjamin (not his real name) knew the extent of her illness. Although they were together for a year-and-a-half, all he knew was that she was sensitive about her eating habits and weight. Extremely sensitive.
“He used to comment on the fact that I could eat more than him,” Rebecca says. “I’d freak out, think he was saying I was fat, and then I’d cry and he wouldn’t know what happened.” After a few of these meltdowns, Rebecca told him she had been anorexic in high school, but wasn’t anymore. She began to run longer and longer distances, over 10 miles a day, and when she started to lose more weight, Benjamin assumed it was from the running.
For her first three years at Vandy, Rebecca was able to keep up appearances. She had the job, the good grades, the fat-free body, the boyfriend, and she went to Vanderbilt. She could sit under an oak tree and read all day if she wanted. She could use the rec center three times in one day and no one would notice. By sophomore year, she had enrolled in the secondary education program at Vanderbilt’s Peabody College.
“I tried losing weight the healthy way, by eating right,” she said. “but it wasn’t fast enough.” photo: ericengland.net
But she wasn’t happy. “Rebecca was always a weird mix of being at times very happy, very social, and at other times extremely moody and sad,” Benjamin says. “She is all of that, all at once. Minute to minute.” Rebecca’s mood swings became more pronounced, and her therapist prescribed Wellbutrin for her depression. Her relationship with Benjamin began to crumble, and eventually they broke up.
She started skipping classes to devote more time to her job as a nanny, and her grades started to fall. She threw up more frequently, up to half a dozen times every day, and her grades slid further. For the first time in her life, she failed a class. Around this time, she began a disastrous affair with the father of the family for whom she nannied.
Then came the drinking. Rebecca used alcohol to help her feel less self-conscious, and to dull the guilt she felt from binging. “I drank by myself in my dorm room,” she says. “I don’t even know how much. I drank beyond anything that might be funny to joke about.” She found another nanny job and spent her days running after toddlers, whittling her body down to a size 00. She skipped meals so she could get drunk faster, then drank too much and wound up jackknifed over the toilet.
Her friends noticed the change—hell, everybody did. But the problem was that Rebecca made a really fun drunk. She hugged people. She danced. She said funny things and laughed at everything. And so her friends clinked their glasses together and said nothing.
The second semester of senior year, Rebecca worked as a student teacher—a requirement for students in Vanderbilt’s teaching programs. When she started at the school, she made a deal with herself that no matter what, she couldn’t throw up during the school day. Her deal only lasted a little over a week. She ate lunch with the teachers, went over syllabi and talked about coursework. Then she would quietly head to the bathroom in the teacher’s lounge.
She was weak. Her heart felt “funny” every time she ran, sometimes even when she did something as simple as walk up a flight of stairs. She couldn’t sleep at night, and during the day she had trouble keeping her eyes open. “I started bringing snacks to school so I could eat enough to stay awake during the day,” she says. “I’d force myself to eat some tomato soup between classes. But then I’d feel guilty and throw it all up.”
One day, she finished teaching her English honors class, waited for her students to zip up their backpacks and shuffle out the door, and then walked to the bathroom, leaned over the toilets and threw up her lunch. Rebecca braced her hands against the metal stall, listened to the students shuffling in and out, sneaking cigarettes or reapplying makeup, and told herself that something needed to change.
“I thought: I can’t do this,” she says. “I can’t be a teacher and have this problem.”
Rebecca called her dad and told him she was leaving Vanderbilt and checking herself into an eating-disorders treatment center—with his permission, and financial support, of course. Her father knew Rebecca had struggled with purging as a teenager, but had no idea the problem had become so serious. He told her withdrawing from school and leaving her friends was a mistake, but Rebecca insisted.
When Rebecca told her therapist she was entering a treatment program for bulimia, the therapist was stunned. She immediately cancelled Rebecca’s Wellbutrin prescription. The drug had been known to cause seizures in bulimics. She demanded to know why Rebecca hadn’t said anything. Rebecca shrugged and said it wasn’t a big deal. “I knew it caused seizures,” she says, “but I just thought it’s in such a small amount of the population, I’ll be okay.”
Rebecca knew she needed to get out of Nashville, so she searched for a program near Washington, D.C., where her older sister lived. A month later, she packed her bags and began a 12-week stay at the Center for Eating Disorders at Sheppard Pratt in Towson, Md.
Rebecca never said goodbye to her friends. She didn’t even tell the school that she wouldn’t finish her student teaching job until the day before she left.
“I told the teacher I assisted that I had to go into the hospital,” she says. “She thought I meant that I had a disease, and I wanted her to think that.” The deception, she believed, would prevent people from thinking she was weak.
“The biggest misconception when treating eating disorder patients is that this is a choice,” Bermudez says. “It’s not a choice. It’s a serious illness. I may choose to start restricting or purging, but my starting undermasks the latent vulnerability—the reason why I need this control mechanism…. Treatment is therefore not simply about medical improvements, but also about getting the patient to a point where they are mentally prepared to overcome the problem.”
The best form of treatment, Bermudez says, is a sort of tag-team scenario with a medical doctor, a therapist and a nutritionist. While such treatment is possible in a regular hospital or as an outpatient, eating-disorder treatment centers provide all three types of care in a single, controlled environment.
For two months, Rebecca lived at Sheppard Pratt. She had to eat three full meals a day, all carefully calibrated by nutritionists, in consultation with therapists. Rebecca, for instance, loved vegetables and hated carbohydrates, so the staff made sure she ate pasta and bread to get over her phobia. She had group therapy sessions, individual assessments, meetings with doctors, arts and crafts, emotional bonding games—every minute of every day was accounted for.
“You weren’t allowed to go to the bathroom by yourself,” Rebecca says. “And when you did go, you had to get someone to give you a key to flush the toilet.”
She met a 50-year-old anorexic woman who was too weak to do anything but sleep. She met a teenage boy who did push-ups to burn calories when the nurses weren’t looking. Rebecca’s problem wasn’t that she wouldn’t eat, but that she ate too much and then purged. When another patient refused to finish a meal, Rebecca ate it for her. She tried to obey the rules, but by now she had been throwing up for seven years. It was something closer to a physical addiction.
“One day I ate a turkey sandwich,” she remembers. “I finished the whole thing before I realized it was too big. I felt too full. So I went and threw it up. I had to get the key to flush the toilet, so of course they found out, but what were they going to do? It was already out.”
Despite the setbacks, Rebecca made progress. She had asked to come to Sheppard Pratt, after all, and she was determined to leave there a healthier person. She told her therapists that she had always felt bad about herself. She wasn’t pretty enough, she was clumsy, she said stupid things. She felt nervous around people, sure they were making fun of her.
Eventually, she worked up the nerve to call her father. They had a long, grueling discussion. “He worked all the time, never said emotional stuff, his role was just to give us money,” Rebecca says. “I told him I was sorry I wasted so much of his money. He bought me food and I just threw it up. And now I was wasting more.”
As she purged these painful feelings, Rebecca found her relationship toward food growing less fraught. The temptation to run to the toilet after every meal began to diminish. For the first time in seven years, she ate ice cream and kept it down.
She left Sheppard Pratt 15 pounds heavier and returned to Nashville last spring. Along with her extra weight, Rebecca returned with a new vocabulary. Today, she can talk about “comfort foods,” “miscommunication” and “thought management.” But she knows none of these catchphrases will help her if she can’t learn to exist on her own.
Her friends tell her she looks good, but she can’t figure out if they mean it, or if they just think they’re supposed to say it. She gave away her smallest pair of jeans, size 00, to an anorexic girl before she left. “I saw them on her,” Rebecca says, “and she just looked so thin I thought: Eww! Did I look like that? I must have been gross.” But when the summer came and she tried to fit into her old clothes, she found they were too small. She wondered if she should do something to make them fit again.
Classes start in a few weeks and Rebecca will be back out there among the size 2’s. There’s no one to make her meals for her, no one to catch her if she scarfs down too much food and decides she needs to get rid of it. There are no drugs to take, or easy explanations to offer, when people ask where she went. She plans to tell most people that she sought treatment for depression. She’s too embarrassed to tell anyone but her close friends the truth.
This year, Rebecca will teach at the same school that she did before. She still wants to be a teacher, but she worries that if potential employers find out about her bulimia, they may not consider hiring her.
“Throwing up is ugly,” she says. “It’s messy and it means I am not an adult. I can’t be an adult until I get over this.”
She hasn’t even told her family that an article is being written about her.
Classes start in a few weeks and Rebecca will be back out there among the size 2’s.
Rebecca and I have been playing phone tag for a couple of weeks, and I’m beginning to worry that she might not want to meet in person, at all. But one day she calls and says she’s free for coffee if I am, and we agree to meet at Fido. Rebecca is already there when I arrive, at a small table in the corner. I almost miss her when I walk by.
This is the first time I’ve seen her since her stay at Sheppard Pratt, but she barely resembles the girl I knew in college. She’s cut her hair, I notice: it falls at her shoulders now instead of partway down her back. Her face is fuller and her shoulder blades don’t jut out anymore.
We make small talk for a while, swap gossip about people we know in common. She smiles and fidgets, the way she always does when she’s nervous. Rebecca has hidden her disorder for so many years that I wonder how much she’ll talk about it in the crowded coffeehouse, with strangers sitting within earshot.
But Rebecca’s stories come easily, and she grows more comfortable the more she talks. She has a new therapist and has started going to Overeaters Anonymous meetings to help stop her need to binge.
“I haven’t officially joined yet, because they make you do this thing, sort of like the 12-step program for AA,” Rebecca says. “And part of it is you have to apologize to the people that you hurt. That sounds scary. So I haven’t done that yet.”
Rebecca says she’s fine during the day. The nights are tougher. “One night I really wanted a vanilla milk shake,” she says, “because I thought it would feel like a hug and I wouldn’t be lonely anymore. But I couldn’t have it, because I knew I’d just throw it up.”
The more she talks, the healthier and more reflective she sounds. Or is that just what I want to believe, because she wants me to believe it? After all that treatment, all that misery; after all those years spent hiding; after relieving the burden of all that secret shame and self-hatred—after walking past me all those years without my knowing or doing anything—healing is the happily-ever-after outcome. Everyone gets better. Right?
Rebecca looks better. But suddenly, in the space of a single sentence, she enumerates the medical problems caused by bulimia—she suffers from chronic heartburn, the beginning stages of osteoporosis and a throat that cannot close properly—then casually notes that she ate too much on a recent evening and had to “get rid of it.”
The mixture of what Rebecca understands—what she’s learned from therapists, what pop culture has promised her, what she believes, and what she pretends to believe—makes a jumbled mess. I picture these ideas colliding and twisting inside her, making her sicker and sicker. Until she can’t keep them down anymore.