Last month, Newsweek tried to put a new face on anorexia. No, not the doe-eyed brunette on the magazine's cover, but the article inside trumpeting the latest theory about the disease: It's genetic. According to Newsweek, the appearance of anorexia among groups not conventionally associated with it (younger girls, nonwhite girls, boys) has made doctors reject the old idea that victims "catch" the disease from cultural influences or pressure-cooker families. Now, doctors compare anorexia to autism and schizophrenia—diseases that psychologists once blamed on parents and that science later showed to be hardwired.
Genetic determinism is the latest in a long line of reductive theories of anorexia. Since the start of the 20th century, the disease has been seen through the prisms of endocrinology, Freudian psychoanalytic theory, developmental psychology, and feminist cultural criticism. It's easy to see why these theories became prevalent. Each offers a simple explanation for anorexics' behavior—brain chemistry, sexual anxiety, a controlling mother, fashion magazines—and in doing so, demystifies a maddeningly opaque disease. And because anorexia is so complex, each theory gets at least part of it right. But the most appealing thing about these interpretations is that they sidestep one particularly disturbing aspect of anorexia, which is that it's at least partly voluntary and willful. That a 10-year-old would choose to do something so counter to nature is hard to accept, so these interpretations of anorexia make her its unwitting victim. Genetic determinism takes such thinking to a logical extreme: It's not her fault; it's in her genes.
From the time the diagnosis was first conceived, experts have discounted anorexics' motives. The disease was named in 1873 by doctors who likened anorexia—a new phenomenon of young girls starving themselves—to hysteria: Both afflictions were thought to result from dangerous upheavals in the bodies of maturing girls. Few 19th-century doctors devoted much thought to anorexics' rationales for their self-starvation. If a girl said she couldn't eat, and offered some excuse like a stomachache, her claim was taken at face value; such symptoms were assumed to be psychosomatic, just like a hysteric's fits of weakness or paralysis. Only one doctor—the "father of hysteria," neurologist Jean-Martin Charcot—suggested that anorexics were motivated by a conscious desire to be thin.
At the beginning of the 20th century, doctors began to seek physiological explanations for anorexia. The hot new field was organotherapy, and early endocrinologists were busy injecting patients with "organ juices" in order to remedy various defects. After the discovery in 1913 of an emaciated woman who had died and turned out, on autopsy, to have a shrunken pituitary gland, doctors began to inject pituitary extract into anorexics. In the '20s, physicians at the Mayo Clinic briefly treated anorexia as a metabolic disorder and tried injecting anorexics with thyroid hormone. Others gave them insulin or estrogen. But the treatments were unsuccessful: The only anorexics who gained weight on hormones were simultaneously being fed a rich diet. By 1940, the idea that anorexia was an endocrine disease had been rejected.
The rise of psychoanalysis around this time led doctors to focus on the psychological causes of the disease. In a 1939 study, a psychoanalyst named George H. Alexander found that one girl's dieting began after two classmates had become pregnant and left school, and deduced that she'd developed a paranoid fear of pregnancy. Based on this single case, Alexander concluded that anorexia was caused by a belief that fat is pregnancy and food an impregnating agent. For a while, this view was taken seriously; into the '60s, doctors referred anorexics to analysts who subscribed to it. But soon, more complex and credible psychological theories emerged.
These theories, developed in the 1960s and '70s by people like Hilde Bruch in the United States and Mara Selvini Palazzoli in Italy, were more empirical and sensitive than most of those that preceded—or followed. Bruch and Palazzoli explained anorexia in developmental and cultural terms. Newsweek'sgloss of Bruch's 1978 book, The Golden Cage—"that narcissistic, cold and unloving parents (or, alternatively, hypercritical, overambitious and overinvolved ones) actually caused the disease by discouraging their children's natural maturation to adulthood"—doesn't do her ideas justice. Both Bruch and Palazzoli did, as Newsweek says, attribute anorexia partly to a girl's failure to develop a sense of independence, but they didn't blame that exclusively on parents. They also linked anorexia to the increasing glamorization of thinness and popularity of diets. The cultural endorsement of thinness, in their view, merely set the conditions that allowed particular girls to discover, in manipulating their appetites and their bodies, sensations of power and accomplishment that they otherwise lacked.
Bruch's description of the tensions in anorexics' families caught the public's attention. Then, in the late '70s and early '80s, popular feminist writers took up the cause. Books like Susie Orbach's Fat Is a Feminist Issue, Kim Chernin's The Obsession: Reflections on the Tyranny of Slenderness, and, 10 years later, Naomi Wolf's The Beauty Myth attributed anorexia to a misogynistic culture that glorified waifs and denigrated real women. By the '90s, health-class presentations on eating disorders often involved rifling through magazines and discussing how unreasonably skinny the models were. Even when I was 12, this struck me as reductive: What girl would possibly be moved to such extremes by an ad for a depilatory?
The new genetic theory, like the others, seems partly right and partly wrong. After all, genetics can't explain why anorexia proliferated in the late 20th century, any more than a narrow feminist argument explains why, even though we're all confronted with images of Giselle's improbable physique, only some people become anorexic. An appropriately complex theory of anorexia would address both environmental and individual factors, in order to explain why it became widespread in the last 40 years and why, still, only certain people get it.
Interestingly, the most incisive interpretations of anorexia often fail to stick in the public consciousness. Two doctors who treated anorexics in Toronto in the 1930s left behind a remarkably astute description of the type: "Most of them are intelligent, some to a marked degree; all are highly sensitive," they wrote. "Usually they are impulsive, willful, introspective, and emotionally unstable." Then, refuting the cliché that anorexics are ruled by insecurity, the doctors suggested instead that they're driven by positive desires: "They have a strong desire for prominence and dominance."
From my own experience (I first had the disease when I was 10) and those of other people I've talked to, this last observation is one of the most important—and least acknowledged. It's easier to see anorexics as victims, whether of social forces or biology, than to imagine that they derive pleasant sensations from their behavior. But they do. The disease often makes them feel special and unique. Until we discard the victim model and admit that anorexia, though destructive, often fulfills a deep personal need, we can't begin to investigate what makes a person vulnerable to it. Evidence that anorexia now affects an unexpectedly wide range of people provides an impetus for a new, more complex theory of the illness. But any such theory must acknowledge the willful aspect of anorexia, instead of trying to turn the disease into something as random and involuntary as a cold.
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