"Skinny, Pretty...and Happy?". Combating Anorexia and Bulimia in Medellín.
by Lucrecia Ramírez Restrepo
Rosario is 21 years old and a perfect size 6. A fifth-semester student in international business in Medellín, Colombia, she's often thought of herself as fat. It all started when she was a child, and her parents encouraged her to lose weight the healthy way—through diet, exercise and good nutrition—so she wouldn't become overweight as an adult since the tendency ran in her family.
But those paths didn't seem to work for her. As she approached her teens, she hated her body; she would measure her waist, arms and hips after each and every shower. She finally discovered vomiting—which we know more technically as bulimia. Then came diet pills and laxatives. When she turned sixteen, she convinced her parents to finance liposuction and breast enlargement. But it was a constant battle to maintain her weight: two hours daily of exercise, pills and starvation. A classmate died of what some said was anorexia—self-induced starvation. But despite the shadow of a possibly dangerous eating disorder, Rosario kept up her regimen to keep her figure—to please her family and boyfriend and to compete with classmates.
Rosario is a composite figure of the young women we see on a daily basis at our outpatient psychiatric clinic in Medellín. Body image is not just a passing concern of adolescents: it affects women (and to a much lesser degree, men) in terms of self-worth, relationships, sexuality, human development and even productivity. It's not just that Rosario invested time and money in staying very thin; that's time and energy she could have spent on her studies and personal enrichment.
The pressures generally come from three sources: mass media, parents and schoolmates. It wasn't always this way. During the 1980s and until the mid-90s, cases of anorexia and bulimia at our clinic—attached to the prestigious University of Antioquia (Hospital San Vincent de Paul) —were considered "exotic”. Two factors came into play: drug trafficking and the development of Medellín as a fashion center, both of which fostered the ideal of extreme thinness, but at the same time sexy and fitness.
The irruption of narcotrafficking at the beginning of the '80s in Medellín meant a very deep and traumatic political, social and cultural change and fracture in our society. Drug kings sought to express their "new power" by buying whatever they wanted: in particular, beautiful women, in the style of the voluptuous Pamela Anderson and the like, associated with the American beauty of those times. Women were exhibited as trophies. A little later, one the projects that the Medellín establishment came up with was the presentation of the city as the Milan of Latin America, creating a Fashion Show and three fairs that featured beauty along the lines of a European concept of beauty with very skinny models. All these fashion-related events exerted much pressure over the city's women. Many felt the need to combine thinness and voluptuosity, as well as fitness— an impossible task from the perspective of health. Women found it necessary to use extreme practices as starvation, exercise until exhaustion, laxatives and plastic surgery.
As the number of cases raised dramatically, city began a project for the prevention of Eating Disorders known as "Skinny, Pretty...and Happy?" in 1997. This program focused on gender equity and the development of economic, social and cultural rights of women as a way of struggling against objectification and dependence on physical appearance.
The program began in the Women's Mental Health Academic Group in the Psychiatric Department at the University of Antioquia, and in the government of the civic movement Compromiso Ciudadano lead by Mayor Sergio Fajardo (2004-2007). The program was incorporated in the programmatic line “women´s development,” which brought together civil society organizations.
The entire intervention had three stages: first with comprehension of the problem (1999-2003), then with implementation of the program (2004-2007), and finally with extensive evaluation (2008).
In order to understand the scope of the problem, two studies looked at the issue, the first one in 1999, in which almost 1,000 high school girls from five elite schools were enrolled in workshops, conversation programs with parents, and lectures. The University of Antioquia study found that 77 percent of the girls were horrified at the idea of gaining weight; 41 percent indulged in binge eating; 33 percent felt guilty after eating; 16 percent felt that food controlled their lives; 8 percent reported self-induced vomiting. The school study sounded the alarm about the severity of eating disorders in Medellín, but it certainly wasn't a representative study because it included only the schools that had called to participate.
A second, more comprehensive study in 2003 using a representative sample of adolescent students, found that in Medellín, 33 percent of them were at increased risk for eating disorders. The study found that the risk was not related to how wealthy or poor the girls were or type of school, public or private, mixed or feminine. The prevalence of the illness estimated those at high risk to be 31 percent. That compared with 5 percent in Spain and 10.2 percent in the United States at the time. The study also confirmed the previously described risk factors as bullying or teasing about weight issues, previous obesity or obesity in the family, and negative comments (sometimes well-intentioned) by friends or family members about body appearance.
Then, the program used three main strategies, to go beyond direct work with adolescents. The idea was to make the environment more friendly to diverse body types and stopping the promotion of the ideal of skinniness.
First, a continuous two-year public health campaign used television, radio, newspapers and ads plastered on billboards in the city (roads, metro stations, bus stops) to denounce the skinniness culture. Catchy images showed strange-looking “skinny” elephants, rhinos and zebras, with the caption, “It looks weird, right?…and you, how do you look?” or Later, in the phase of social awareness, the text of the billboard warned, “Hey! Be careful!, The skinniness culture has fomented anorexia and bulimia, a socially contagious illness.” Later, in the resistance phase, captions declared, “Even if the skinniness culture is powerful, there is no such power greater than the resistance capacity of society.”
In addition, the educational sector conducted 273 workshops in 425 high schools, which worked with 3.294 adult men and women (teachers and parents) through 569 institutional projects they design and implemented, to develop new concepts of femininity, female beauty, women´s contemporary capacities and what it means for a 21st- century woman to be accepted in society.
Finally, a citizens' network for social responsibility was created from health institutions, universities, gyms, schools, local television and print media, dance academies, modeling agencies and artists, to make them aware of the role they might play in fomenting (or preventing) eating disorders and introduce structural changes in their own businesses in order to contribute to decrease the social pressure on the idea that women have to be skinny to be desirable, recognized and happy.
The project, for example, resulted in a rule that models had to undergo a nutritional evaluation before they could participate in the2007 fashion fair Colombiamoda. The Institute for Exports and Fashion (Inexmoda) developed the regulations with the support of the network of eating disorder activists. Since these fashion icons provide role models for teenagers, the institute banned models with extremely low body mass index (BMI, the proportion of fat to height and weight). This rule—an act of social responsibility— represented a powerful acknowledgment that fashion plays a significant part in establishing what is beautiful. In the sector of fitness clubs, Bodytech, a national chain, eliminated all photos of abnormally thin women, substituting more normal and diverse women as a sign of a socially responsible attitude for women´s life and wellbeing.
Things are changing slowly, as a careful data-based monitoring process of the project in 2008 indicated. Adolescents are now developing an evolving concept of femininity. Women are less frequently perceived just as objects for others’ pleasure or appreciation and more in the context of self-worth. There's an emphasis placed on kindness and self-development, as well as beauty. But that's far from suggesting that the problem has gone away.
Femininity is still closely associated with beauty, so now you'll hear phrases like "I want to be a great professional, but not give up being feminine in the process" or "I want to be my own person, but also to be seen as beautiful by others." In addition, women still see appearance as a key to getting a good job or getting ahead in general. Today, in the 21st century, despite all the interventions and progress, the culture is giving its (young) women this message: "It doesn't matter how intelligent, capable, honest, hard-working, collaborative, compassionate,. attentive and diligent you are...if you are not pretty, you're worthless....whatever effort you put into being beautiful is justified because in this way we guarantee your inclusion, recognition and opportunities."
Beauty continues to be seen as thinness. Interviews with adolescents reveal a lack of consensus about the marketing of skinniness. Some observe they have role models in fashion or television who are far from thin; they even observe that pleasantly plump is becoming fashionable. But many others insist that social pressure makes them want to be thin at any cost.
This variety of opinions is a little bit of progress. The model of prevention of eating disorders developed by the city of Medellín was innovative because it starts with the premise that these disturbances are profoundly rooted in the ideas societies hold about women. In the end, after ten years of combating the thin beauty ideal, the rates of developing eating disorders have dropped when social pressures over women's body appearance has been reduced. There's hope for breaking the concept of "thin is beautiful, and the thinner, the better, and beauty leads to happiness."
Lucrecia Ramírez Restrepo is a clinical psychiatrist in Medellín, retired professor at the Psychiatric Department at the University of Antioquia, who specializes in eating disorders.