The pop culture-loving contingent of the mental-health community was already on high alert when Netflix dropped a trailer for its new film, To the Bone, in June. Three months earlier, the platform's series 13 Reasons Why had prompted an outcry amongst mental-health experts, who argued the film could possibly initiate a suicide "contagion" effect. (A Florida superintendent even claimed that threats of self-harm and suicide had increased in his district following the series' premiere.) So when the promo for To the Bone arrived, portraying a protagonist, Ellen (Lily Collins), with anorexia nervosa, scrutiny was—perhaps understandably—intense.
The trailer opens with Ellen sitting in front of a plate of food, counting calories; it cuts to Ellen grimacing through evidently painful sit-ups, followed by a graphic shot of her doctor examining a prominent spine protruding from her emaciated back. Experts protested that images of a very thin Collins, who lost weight for the role, could potentially act as "thinspiration," inadvertently serving as a weight or appearance goal for people with eating disorders. The film was also accused of perpetuating the stereotype that only young, white women have eating disorders.
Though they presumably hadn't see the full film, which debuted Friday, these experts had good reason to fear another Hollywood movie about a protagonist watching his or her weight. After To the Bone lit up social media, I reached out to three different experts to ask for movies or television shows that had treated eating disorders with nuance. All three—Dr. Angela Guarda, director of the Eating Disorders Program at the Johns Hopkins University; Kelly Williams, a National Eating Disorders Association representative; and Melissa A. Fabello, a body image expert and eating disorders writer—said that there are no truly satisfactory onscreen depictions of eating disorders. Fabello was the only source to produce a title that avoided some stereotypes: Degrassi: The Next Generation, which has featured two male characters with eating disorders, and at least one female character who openly discusses the challenges of recovery.
Since the film's release, critics have grouped To the Bone with other anorexia films that feed America's cultural curiosity about too-thin women, and called it a bore. Certainly, its creators tried to portray it right: The story is loosely based on director Marti Noxon's own experiences with disordered eating. But though the National Eating Disorders Association has published guidelines for responsible media portrayals of eating disorders, they have proven uniquely tricky to portray onscreen. The reality of eating disorders does not lend itself well to script material—leading Hollywood to gloss over some of these diseases' deepest pains, and foreground unrepresentative characters.
To some extent, Hollywood is catching up like everyone else when it comes to understanding eating disorders. While anorexia nervosa has been included in the Diagnostic and Statistical Manual of Mental Disorders since its first edition in 1952, eating disorders did not receive their own entry in the DSM until 1980. Eating disorders weren't widely recognized in American culture until the 1970s, at a time when both eating-disorder cases and rates of obesity were on the rise in the United States. Whether due to scant research, a cultural fixation on weight, or a combination of both, a broad understanding of eating disorders has been missing in American mainstream culture for a long time.
But the symptoms of eating disorders aren't particularly cinematic in themselves, which has provided another challenge for filmmakers to contend with. Research has demonstrated that eating disorder sufferers tend to distrust others, and prefer not to talk about food; bulimia nervosa has particularly been associated with social withdrawal. A movie candidly depicting eating disorders, then, would involve little dialogue and a lot of repetition—elements that are worth experimenting with, but might not lead to box-office success.
"The truth is: Eating disorders are ugly," Fabello says. "They're scary. They're sad. They're silent."
Instead of telling narratives about how miserable it is to feel alone, hating your body, and barely trusting anyone close to you, Hollywood has—perhaps understandably—produced several dramatizations with happy endings. Take the infamous 1990 crash diet episode of Full House, in which young teenager DJ Tanner (Candace Cameron-Bure) starves herself and works out extensively for several days in order to lose a few pounds. Through the magic of TV, she is cured after a heartfelt talk with her family, portraying anorexia as a means to the end of bringing the Tanner family closer together. That's hardly a realistic outcome of the disease, or a responsible message to convey to impressionable sitcom watchers. Pressure from loved ones can prompt a person with an eating disorder to seek treatment, but not usually after a minutes-long chat. Eating disorders, after all, have a notoriously high relapse rate and the majority of people with anorexia recovery after 20 to 25 years, a 2017 study found. "It is rarely, if ever, an 'aha moment' of insight and change," Guarda says.
Instead of telling narratives about how miserable it is to feel alone, hating your body, and barely trusting anyone close to you, Hollywood has—perhaps understandably—produced several dramatizations with happy endings.
Starving in Suburbia, a 2015 Lifetime movie about a young dancer who has anorexia, embodies another oft-used, inaccurate Hollywood trope about eating disorders: that it is a disease predominantly suffered by young, middle-class white women who are (usually) already thin. The film centers on a girl named Hannah (Laura Wiggins) who joins a "thinspiration" website that spirals her into a serious disease. That Hannah's eating disorder begins online addresses the harms posed by "thinspo" online communities. But instead of portraying a realistic, solitary online existence, the film places Hannah in a physical, fantasy chat room, where another character whispers in her ear, to depict her virtual chats.
Examples of these two tropes—cinematic shortcuts and young, white, female protagonists—abound in movies about eating disorders: Take NBC's 2007 made-for-TV movie Perfect Body about Andie (Amy Jo Johnson), a young gymnast who develops bulimia after her coach criticizes her weight. It includes a scene where the main character and a fellow gymnast discuss the "benefits" of being bulimic for dramatic effect; in the end, Andie's parents and coach shoulder the blame for her eating disorder in a cathartic ending in which Andie's participation in group-therapy is mentioned only casually.
Little Miss Perfect, a movie loosely based on Beauty and the Beast that debuted at the Irvine International Film Festival in 2016, follows a young woman who is stressed about school and develops an eating disorder after reading about them online. The film does provide some helpful information for viewers: Belle goes to treatment for her disordered eating, and a health worker explains to her dad that relapses are common. But again, the protagonist is a young, already thin, white teenage girl who lives comfortably—her disorder is a manifestation of a troubled quest for perfection.
While women do, in fact, have eating disorders at higher rates than men, according to the NEDA, men comprise 25 percent of people with anorexia nervosa or bulimia nervosa, and 36 percent of people with binge eating disorder. While there has been little research done on race and eating disorders, researchers agree that eating disorders affect people of all races. NEDA further explains that, because eating disorders have always been treated as a white woman's issue, researchers haven't paid enough attention to eating disorders among people of color.
One study, published in 2006, examined how race affects physicians' diagnoses of eating disorders. It found that doctors were more likely to diagnose a fictional white patient who reports disturbing eating problems than black patients. Doctors "may have race-based stereotypes about eating disorders that could impede their detection of symptoms in African-American girls," the authors concluded.
"When we are continually given the same story over and over again, we start to believe that it's the only story—and that leaves more marginalized experiences invisible. That's dangerous," Fabello says.
"When we are continually given the same story over and over again, we start to believe that it's the only story—and that leaves more marginalized experiences invisible."
How could Hollywood creators make more informed films about eating disorders? Fabello says she would be impressed with a film that "featured a person of color, a fat person, a person with [binge eating disorder]—or all of these at once." She also says that it's important to find ways of telling these stories that are suggestive, rather than explicit: "We don't want to give viewers a manual for how to better perform and hide their eating disorders."
Guarda adds that filmmakers could emphasize that one recovers from an eating disorder—as most do—through treatment that helps patients create healthy eating habits and, if they are underweight, brings them up to a healthy weight. She says that films would do well to also include plots where loved ones encourage a sufferer to get help, providing an audience with practical, helpful information.
Though Hollywood has long struggled to depict stories about mental illness, filmmakers interested in portraying eating disorders might take a cue from movies covering addiction. Nobody leaves Requiem for a Dream, a movie about three heroin addicts, thinking drugs are sexy or fun, but rather with a visceral sense of the destructive, dangerous, and desperate nature of addiction. Grim though the film is, audiences and critics still praised it upon release, in large part owing to direction from Darren Aronofsky that highlighted addiction's consequences, rather than its glamour, and an arresting soundtrack.
For their part, To the Bone's filmmakers made a real effort to shine a light on eating disorders with a candid, informed story. The film's director and star (Collins) have been vocal about their own struggles with eating disorders in press for the film in an attempt to make the film a talking point. Noxon has said she consulted with experts who work for Project Heal, an organization that awards grants to people who suffer from eating disorders but cannot afford treatment, in the making of the film.
But the road to dangerous stereotypes is evidently paved with good intentions. For Hollywood to tell stories about eating disorders well, they might follow their critics' advice, and reflect the length, solitude, and paranoia that eating disorders really entail—and the spectrum of people that suffers from them.