The commented that he sent Hadley Freeman, anorexic as a young girl, seemed benign. A classmate who was skinny said she was envious because she wished she was “normal like you,” an innocuous remark that sent Freeman spiraling into self-starvation. As she notes in Good Girls: A History and Study of Anorexia, there’s a difference between a trigger and a cause: anything can have a similar effect because she was so vulnerable. For women and girls prone to the condition, she writes, “anorexia was a bomb inside of us, just waiting for the right moment, the one flame, the trigger.”
Freeman, a contributor to The Guardian, reveals her story with the disease, which spanned her teenage years and early adulthood in the 1990s. She also tracked down former patients at the hospitals where she spent time as a teenager and interviewed more than a dozen psychiatrists and other medical professionals. Her goal is to better understand a condition that haunted her youth and has long resisted explanation and treatment.
Anorexia nervosa is an eating disorder in which people restrict their food intake and lose weight, sometimes fatally. Most with the disorder are women — Freeman puts the figure at 90 percent — and although the condition affects less than 1 percent of the population, there has been an increase in cases among children under 12 in recent years. During the Covid-19 pandemic, related hospitalizations also rose. Anorexia has the highest death rate of any mental illness, Freeman notes.
By her own admission, Freeman’s disease was a fairly classic case of anorexia. She developed the disease at age 14, resulting in nine hospitalizations (double the number of most patients she had known) in four different institutions between 1992 and 1995. Privately educated, she attended all-girls schools in New York and then in London with the children of minor celebrities as her peers.
Early on, she questions the assumption that anorexia largely affects white, wealthy girls; Black children, like other children of color, may be less likely to recognize their illness, she points out. And poor white children develop anorexia too. (Although men also experience eating disorders, she chooses to focus on women in the book.)
Still, she writes, “The cliché about anorexia and privately educated white girls is not the whole story. But that’s very different from saying it’s the wrong story. After all, few embody that story more fully than I do.”
Research shows that eating disorders are highly heritable: 60 percent, compared with 30 to 40 percent for depression and anxiety, according to psychiatric geneticist Jerome Breen.
Freeman has read studies and talked to a wide range of experts, skillfully weaving their views into her narrative. She notes, for example, that a potential link between anorexia and autism spectrum disorder was first drawn as far back as the 1980s. But the symptoms of starvation can mimic those of ASD, Freeman writes. It can be difficult to distinguish anorexic girls who are not autistic but exhibit ASD behaviors as a result of their affliction from those who also have autism, says Anna Hutchinson, a clinical psychologist.
Gerome Breen, a psychiatric geneticist at King’s College London, sees more connections between anorexia and obsessive-compulsive disorder and suggests that metabolic factors are also at play, such as connections between appetite-controlling hormones and insulin. People with anorexia often have a high metabolism and low blood sugar, Breen says. “So there’s probably an interaction between metabolic and psychological processes, in the sense that weight loss may be rewarding for them or elicit a greater degree of response than it would in someone with a less robust metabolism.”
In addition, research shows that eating disorders are highly heritable: 60 percent, compared with 30 to 40 percent for depression and anxiety, according to Breen. Freeman traces her tendency toward anorexia from her mother to her grandmother on her mother’s side and on her father’s side as well. “Perhaps there was a dynamic in my family that taught me that food was the vehicle through which women expressed unhappiness,” she reflects.
One of Freeman’s early clinicians was a man she calls Dr. R.—a predatory figure who later lost his medical license for a “murky and secret relationship” with a patient. He presided over the first hospital ward she entered, visiting her once a week to select the patient to attend to. In the 1990s, eating disorder units were “ridiculously patriarchal,” she writes. “The male consultant was the king, invariably the female nurses reported to him, and we patients were the lowly peasants who did what the big man and his maids told us.”
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Freeman, whose previous books include her family memoir House of Glass: The Story and Secrets of a Twentieth-Century Jewish Family, brings her signature sense of irony to this story. She nails the isolated strangeness of her anorexia in a self-portrait that is both tragic and almost laughable. “I talked to myself all the time when I was anorexic, silently and out loud,” she writes. “Who else would understand the sweet victory of squeezing in extra crunches that weren’t even on my own schedule?” As for the cliché that intelligent girls are more likely to develop anorexia, she notes, “As a noted international genius, I humbly endorse that theory.’
Another fascinating aspect of the narrative is the personal stories of other former patients, showing how different women coped after the disease. One woman, Alison, came straight from an eating disorder clinic to the bar where she and Freeman met. A 52-year-old married mother of two, she had recently relapsed and was trying to hide the extent of the disease from her young sons. She actually looked back quite fondly on their time in the hospital – there were boundaries and safety and she was allowed to eat. “It was a laugh in the hospital, which sounds bad, but it was, right?” she tells Freeman.
Part of Freeman’s purpose in recounting her treatment in the 1990s is to explore the ways in which clinical practices have evolved over time. She simply omitted the forced tube feeding favored by practitioners in the 1980s (although it remained as a potential threat that “loomed over me, a hangman’s noose”). Dr. R recommended electroconvulsive therapy—still considered a possible intervention today—which her parents refused.
At the time, the approach to forcing anorexic patients to eat was primarily punishment and reward. (The therapy took too long, she suggests.) That strategy has since been discredited. In some eating disorder units today, patients are allowed to continue some anorexic behaviors, such as exercise and vomiting, Freeman notes, until they gradually learn more resistant behaviors.
And because of better understanding of co-morbidities like autism, inpatient wards are now being designed in ways that take into account noises, colors and tastes. A nurse tells Freeman that instead of making all hospitalized patients eat the same food and gain weight at the same rate, treatment now aims to encourage preferences and encourage patients to associate food with pleasure rather than punishment .
“There’s a genetic predisposition, a little brain disorder, some metabolic factors. Then there are things that interact with development and time, such as people being perfectionists, high achievers, having several social problems,” Janet Treasure said.
Christopher Fairbairn, a British professor of psychiatry, has developed an approach called cognitive-behavioral-enhanced therapy, or CBT-E, that encourages clinicians to engage patients on an individual level by understanding their perspectives and working with them to develop personalized meal plans. It is now considered the leading approach to the condition, Freeman writes, and is widely used in the United Kingdom, the United States and New Zealand.
As Freeman walks readers through the various theories of the condition, what becomes apparent is how defiant it is to scientific explanation, even for experts who have spent their lives working with anorexia patients. The best answer so far is that it is caused by a combination of nature and nurture. As Janet Treasure, a leading specialist and the last psychiatrist to see Freeman, noted, “There’s a genetic predisposition, a little brain disorder, some metabolic factors. Then there are things that interact with development and time, such as people being perfectionists, high achievers, having several social problems.
Many memoirs have been written about anorexia, perhaps the most notable being the Pulitzer Prize-nominated Wasted by Maria Hornbacher, whose poetic meditations on the subject cannot be rivaled: Eating disorders are, Hornbacher argues, at least in part about “the stumbling of the individual blindfolded – walk through an increasingly strange world.
Freeman’s book brings to the genre a blend of humor, humanity and reporting driven by a very personal curiosity. She reveals that she spent years no writing about this topic; now she’s done it in the hope that young people like her — and the parents who quietly turn to her with questions — will feel less alone and know that life can get better. But even experience cannot fully illuminate the condition.
“After you’ve talked to enough eating disorder specialists, you realize that even now, after all this time, after all these girls and women have gotten sick and died, nobody really has definitive answers about who develops anorexia and why.”
If you are struggling with an eating disorder, call or text the National Eating Disorders Association at 1-800-931-2237.
Frida Klotz is a Brussels-based journalist covering culture, health and reproductive medicine. Her articles have appeared in the Guardian, Irish Times, Al Jazeera America, Mosaic Science and other publications.