Position Paper on Pro-Anorexia and Pro-Bulimia websites

Written by the Royal College of Psychiatrists in collaboration with Beat.

Background:

The eating disorders, anorexia nervosa, bulimia nervosa and related disorders, are biologically based serious mental disorders with high levels of mortality, physical and psychological morbidity and disability and impaired quality of life (Klump et al., 2009). Cognitive and emotional functioning are impaired and this may make engagement in treatment difficult. These disorders have a peak age of onset in adolescence, at a time in life when peer influences are particularly strong. Social contagion effects in the onset and maintenance of eating disorders have been noted, such as the clustering of eating disordered attitudes and behaviours in peer/friendship groups of young people and also within wider social units (schools) or geographical units (Paxton et al., 1999; Forman-Hoffman and Cunningham, 2008).

What are pro-anorexia websites and what is their effect?

Pro-anorexia ('pro-ana') and pro-bulimia ('pro-mia') websites advocate anorexia nervosa or bulimia nervosa as a life-style choice rather than as serious mental disorders, and typically contain tips and tricks on how to maintain or initiate new anorexic/bulimic behaviours and how to resist treatment or recovery (Norris et al., 2006; Harshbarger et al., 2008). The most frequent motivation cited by users of these sites is to maintain motivation to lose weight, to get personal support and to meet other people with eating disorders.

Such websites have been in existence since the development of the internet, but have grown significantly in recent years (OPTONET, 2008) and are now available on social networking sites like Facebook. The limited research available has shown that a significant number of teenage girls visit these sites, in particular those at high risk of eating disorders. A substantial proportion of young people who already have an eating disorder also visit them, in particular those with a more severe form of the illness. Nearly all report learning new weight loss techniques from these sites. Worryingly, young people with eating disorders also report learning new weight loss techniques from pro-recovery websites (i.e. those set up by people who have overcome an eating disorder), although to a much lesser extent than from pro-eating disorders sites. Parents of eating disorder sufferers have a limited awareness of pro-anorexia sites and of their child's use of such sites (Wilson et al., 2006).

What attempts have been made to deal with these sites?

In the UK and USA a number of position statements from reputable organizations for patients, carers and professionals in the eating disorders field have expressed concerns about the effect of these sites on vulnerable young people (Beat, AED, NEDA, ANAD).

In the UK an Early Day Motion was tabled in Feb 2008 by a LibDem Member of Parliament calling on the Government 'to investigate ways to deal with such sites, which cause devastation for people and families, and to support sites which offer help and advice to victims and parents'.

In March 2008 the Byron review on 'Safer Children in a Digital World' was published by the Department for Children, Schools and Families and the Department, for Culture, Media and Sport (www.dcsf.gov.uk). The review proposed the development of a 'national strategy for child internet safety which involves better self-regulation and better provision of information and education for children and families'. The conclusions from this review were fully accepted by the House of Commons Culture, Media and Sport Committee which in July 2008, published a report on 'Harmful content on the Internet and in video games'. In Sept. 2008, a UK Council for Child Internet Safety was launched by the Government. One of its key tasks will be to develop a Strategy for Child Internet Safety. A detailed action plan with milestones, based on the Byron review has also been published, detailing how the newly established Council in collaboration with the industry and other partners will develop an independently monitored voluntary code of practice for the internet industry, will raise awareness of e-safety amongst parents, children and others, and will support schools to deliver on e-safety. These initiatives do not specifically refer to pro-eating disorders websites, but their content is highly relevant in this context.

Legislators in other countries have also been concerned. In France, there were attempts to make pro-eating disorders sites illegal in 2008, but the bill was ultimately not passed. In the Netherlands, the Minister for Youth and Family called for 'click-through warnings' to be added to all pro-anorexia sites hosted on Dutch internet services earlier this year (cited from http://en.wikipedia.org/wiki/Pro-ana).

The responses of internet and social networking site providers to questions and complaints about such sites have been varied, ranging from reluctance to censor or ban such sites to deleting them or inserting banners adverts into these sites, advertising pro-recovery organizations (cited from http://en.wikipedia.org/wiki/Pro-ana).

Summary and Call for Action

There is growing evidence that pro-eating disorder websites attract vulnerable young people at risk from eating disorders and also those with eating disorders. These sites have harmful effects on users as they intensify weight/shape concerns and negative affect, and introduce users to new methods of weight loss. Parents usually have little awareness of these sites.

In view of this, we make the following recommendations:

(1). We applaud the Government's efforts to increase child internet safety via the newly launched UK Council for Child Internet Safety, and through industry self-regulation, an integrated child e-safety strategy and a clear action plan. These plans should include pro-eating disorder sites in their discussions of harmful web-content.

(2) Pro-eating disorder websites are likely to be set up and maintained by young people who themselves have an eating disorder. In view of this, making them illegal would lead to criminalising a vulnerable group of young people. The Byron action plan mentions 'joint working between industry and the third sector to improve the support offered to vulnerable groups, including providing links to support services and improving moderation practices where users discuss harmful behaviours'. These measures should be extended to explicitly include pro-eating disorders websites.

(3) Likewise, the measures proposed in the Byron action plan to raise awareness of e-safety amongst parents and teachers should specifically address pro-eating disorder sites and their harmful effects. Such educational efforts need to be coordinated with wider efforts to educate parents and teachers in the early detection and management of eating disorder symptoms.

(4) We call upon the media not to make pro-ana websites into headline news, not to report their content in a sensationalised way and not to report how to access them, as this may lead to increased use of such sites. Guidance for the media on reporting of pro-ana sites should be part of the development of wider guidance to them on de-sensationalising reporting on eating disorders in general. There are clear parallels here to the area of suicide prevention where it has been shown that the way in which suicides are reported can in- or decrease suicide rates (www.afsp.org).

(5) We acknowledge that eating disorders often leave sufferers feel isolated, ashamed and cut off from support and that on-line support is an easily accessible and powerful way of providing support to those people. We encourage young people with eating disorders and their families to use reputable sources of information and support as that provided by Beat.

Appendix:

Research Evidence on Pro-ana/pro-mia sites

Several studies have investigated pro-anorexia websites. Several key findings emerge:

· Key website characteristics of pro-eating disorder sites included 'thinspiration' content (inspirational photo galleries and quotes that aim to serve as motivators for weight loss) (92%), creative expressions (e.g. poems, stories (75%), calculations (body mass index/basic metabolic rate, calories burned) (67%) and "tips and tricks" (67%). (Norris et al., 2006).

· The "Tips and Tricks" section of these sites are most commonly directed at dieting/restricting calories (28.4%) and self-distraction to reduce hunger (13.9%). 11.1% of comments are directed at concealing symptoms and deceiving health care providers (Harshbarger et al., 2008).

· In healthy young women, viewing such websites induces negative affect, low self esteem and more negative views about their appearance than viewing a comparison website related to female fashion (using average-sized models) or home décor. Additionally, young women viewing such sites perceived themselves as heavier, report a greater likelihood of exercising and thinking about their weight in the near future, and engage in more image comparison (Bardone-Cone and Cass (2007).

· Viewing such websites is common and appears to attract vulnerable young people: In a study of 13 to 17-year old school children 12.6% of the girls and 5.9% of the boys had visited such websites (Custers and Van den Bulck, 2009). Girls who visited pro-anorexia sites had a higher drive for thinness, worse perception of their appearance and more perfectionism, i.e. they are a high risk group for the development of eating disorders. Given the cross-sectional nature of the study it is not possible to know what is cause and effect here.

· In a large survey of university students, women who used pro-eating disorder websites were found to have higher levels of body dissatisfaction and eating disturbance than a control group (Harper et al., 2008). The cross-sectional nature of this study makes it difficult to distinguish cause and effect here.

· In a study of eating disorder patients and their parents, 35.5% of patients reported visiting pro-ED websites. 41% visited pro-recovery sites, and 48.7% visited neither. The number of hours that users spent on pro-ED websites varied widely, with a mean site usage of 2.8 hours per week (SD 4.5) and some patients using the sites up to 20 hours per week. The main motivation cited by pro-ED site users was to maintain motivation for weight loss (70.8%), support (37.5%); or to meet with others with EDs (37.5%). While visiting pro-eating disorder sites, 96.0% reported learning new weight loss or purging techniques. However, 46.4% of pro-recovery site visitors also learned new weight loss or purging techniques. Pro-eating disorder site users had a longer duration of illness than non-users, but did not differ from nonusers in health outcomes. About half of the parents reported being aware of pro-ana sites in general. A similar proportion did not know whether their child visited these sites. Only 27.6% had discussed pro-ana sites with their child. Most (62.5%) parents, however, did not know about pro-recovery sites, i.e. sites set up by eating disorder sufferers who have overcome their disorder (Wilson et al., 2008).

References:

Abbate Daga G, et al. Eating disorders and the Internet: cure and curse. Eat Weight Disord. 2006 Jun;11(2):e68-71.

Bardone-Cone AM, Cass KM. What does viewing a pro-anorexia website do? An experimental examination of website exposure and moderating effects. Int J Eat Disord. 2007 Sep; 40(6):537-48.

Brotsky SR, Giles D. Inside the "pro-ana" community: a covert online participant observation. Eat Disord. 2007 Mar-Apr;15(2):93-109.

Byron review: Safer Children in a Digital World. Published by the Department for Children, Schools and Families and the Department, for Culture, Media and Sport. www.dcsf.gov.uk

Custers K, Van den Bulck J. Viewership of pro-anorexia websites in seventh, ninth and eleventh graders. Eur Eat Disord Rev. 2009 Jan 13.

Forman-Hoffman VL, Cunningham CL. Geographical clustering of eating disordered behaviors in U.S. high school students. Int J Eat Disord. 2008 Apr;41(3):209-14.

Giles D. Constructing identities in cyberspace: the case of eating disorders.Br J Soc Psychol. 2006 Sep;45(Pt 3):463-77.

Harper, K, Sperry, S., Thompson, J K (2008), "Viewership of pro-eating disorder websites: Association with body image and eating disturbances", International Journal of Eating Disorders 41 (1): 92-95.

Harshbarger JL et al. Pro-anorexia websites: What a clinician should know. Int J Eat Disord. 2008 Nov 29.

House of Commons. Culture, Media and Sport Committee. Harmful content on the Internet and in video games. Tenth Report of Session 2007-08. Volumne I. Report, together with formal minutes, oral and written evidence. HC 353-I. Published on 31st of July 2008 by authority of the House of Commons. London: The Stationery Office Limited. .

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Mulveen R, Hepworth J. An interpretative phenomenological analysis of participation in a pro-anorexia internet site and its relationship with disordered eating. J Health Psychol. 2006 Mar;11(2):283-96.

Norris ML, Boydell KM, Pinhas L, Katzman DK. Ana and the Internet: a review of pro-anorexia websites. Int J Eat Disord. 2006 Sep;39(6):443-7.

2008 International Internet Trends Study. Optenet, 2008-09-24, http://www.optenet.com/mailing/pdfs/TrendReport.pdf, retrieved on 25th of May 2009.

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influences on body image concerns, dietary restraint, extreme weight-loss behaviors, and binge eating in adolescent girls. J Abnorm Psychol. 1999 May;108(2):255-66.

Wilson JL, Peebles R, Hardy KK, Litt IF.Surfing for thinness: a pilot study of pro-eating disorder Web site usage in adolescents with eating disorders. Pediatrics. 2006 Dec;118(6):e1635-43.