ANA can be highly emotional and empathetic, as well as tormented and victimised.
"Ana" is not a real person but an identity, adopted as self, friend and foe, the embodiment of anorexia. Her speech is the self-talk and self-hate that typifies a condition that is all about internalising how you look - or think you look - on the outside, and clinging to the conviction that salvation lies in getting ever thinner.
Ana (short for "pro-ana" or pro-anorexia) and her lesser known sibling Mia ("pro-mia" ie pro-bulimia) are the subjects of countless posts on social media and dedicated websites, blogs and forums. Even in 2008, the Eating Disorders Foundation of New South Wales estimated there were more than 1 million such sites.
Pro-ana is dedicated to encouraging and supporting those who identify with the community. There are tips on grim topics such as how to make yourself vomit (known as "purging", one involves dental floss and a Lifesaver). There are images of skinny models, celebrities and users' own "selfies" (called "thinspiration" or "thinspo", which the community believes helps keep them motivated, but specialists believe can "trigger" a disorder's onset or relapse). And there are heart-felt posts describing good days and bad, and real-time messaging from Ana "buddies".
It's a vast archipelago of anorexics, with hints that beyond is a secret, subterranean realm of invitation-only pro-ana communities on Facebook and elsewhere. A virtual anorexic nation.
Those who participate in the subculture appear to be overwhelmingly teenage girls and young women - although online, of course, it is impossible to be sure - using handles such as "anything2bethin" and "beautifulbones". The tone of the sites combines the language of support groups and their cycles of hope, commitment, breach, despair and recommitment, with a slightly childish emo folksiness (poetry in scratchy fonts, artwork of waifs wearing knee socks) and a rather more grown-up pride in their perversity.
Coffee and smokes/and cold Diet Cokes/That's what pretty girls are made of.
Its manifest catharsis is profoundly shocking.
EMMA, 21, has struggled with an eating disorder for five years (her surname has been omitted to protect her privacy at her request). She has starved herself ("restricted") for up to eight days at a time ("No food whatsoever and zero-calorie drinks. And I end up a mess after it. I do really want to stop it."). She has seen a range of psychologists, counsellors, dietitians and support groups to help her break a cycle of fasting and bingeing, and deal with her related anxiety and self-harming.
While still at school, Emma says, she told her friends about her messed up behaviours, but, after that one tearful night, they were never mentioned again. She feels lonely and isolated. She has to force herself to leave the house, other than to go to work, and she avoids talking on the phone.
Having always done a lot of research online, Emma stumbled into the pro-ana community at the beginning of the year.
"It's actually nice to read," she says. It makes me feel like I'm not alone, like other people are going through these things and people understand."
Emma's partner and family are aware of her struggles with eating but not her pro-ana participation. Intelligent and articulate, Emma is ambivalent about the subculture.
"I go through stages where I think pro-ana is a fantastic idea, and I get right into it, I read about it and I look for buddies. Then all of a sudden I'll binge and then I'll be, like, obviously, restricting isn't a realistic plan for me."
Her life is dominated by the disorder, she says, every day an exhausting struggle with whether she will try to eat normally or fast.
"Even if I try and eat normally, because I've developed a habit of bingeing, I'll still binge. If [that] happens many times, I feel like I can't do it anymore, I need a break. And so I'll go back to restricting. pro-ana is sort of there for when I can't fight anymore."
Yet she is clear-eyed about pro-ana's hazards. "It does scare me too," she says. "I [was] talking to someone on there once . . . and she was 13 or 14, and that just breaks my heart. I feel like saying 'stop, don't get into this mess, get out of it while you've got the chance'."
Most eating disorder specialists and support groups are unequivocal about the dangers of the sites.
"I absolutely hate them," says Christine Morgan, chief executive of the Butterfly Foundation, the national support group for sufferers and carers. Those with long-term eating disorders don't want to get well, she says. "That's one of the most horrific aspects of the illness.
"The sites say that [people] have chosen this as a lifestyle. We know that's not true, we know that it's a very serious psychiatric illness. Then they encourage them to remain true to those behaviours that are doing them harm. So I can't see anything positive in that from any perspective."
Two million people in Australia will suffer from an eating disorder in their lifetime, the foundation estimates. Disorders last an average of 15 years, and about 20 per cent of sufferers never recover. It estimates the health costs at about $100 million last year, with an impact on national productivity of about $15 billion. The physical damage resulting from anorexia, bulimia and bingeing can include anaemia, osteoporosis, an increased risk of infertility and kidney failure. The foundation estimates in 2012, about 1828 sufferers died.
Beyond the mortality rate and physical impairment, two of Australia's leading experts in eating disorders argue the behaviours must be understood as a mental illness because of the huge distress they cause.
Professor Phillipa Hay, chair of mental health at the University of Western Sydney, likens eating disorders to depression. "In the course of human experience, it will be normal to feel low in the same way as someone with depression feels low. But for someone with a mental illness, [it] becomes overwhelming and prevents them from living full and happy lives and relating to other people. It's the disability from the behaviour and emotion that constitutes an illness."
Professor Susan Paxton, from La Trobe University's School of Psychological Science, agrees. "[Disorders] disrupt a person's life such that in many situations, it's difficult for people to have relationships or jobs or to live independently," she says. "They are a serious mental health problem, and attempts to legitimise them [as occurs on pro-ana sites] are part of the pathology of the disease."
Internationally, there has been momentum in several countries to ban or attach warnings to pro-ana sites, including the United Kingdom and the Netherlands. In France in 2008, legislation to criminalise encouraging others to seek excessive thinness, punishable by up to two years' jail, passed the National Assembly but stalled in the Senate. In Australia the same year, federal Labor MP Anna Burke called for similar legislation to be enacted.
Companies that host pro-ana material, such as Tumblr and Facebook, have also come in for criticism. Some have made efforts to remove pro-ana material, but are often thwarted by rebirthing under different terms ("thynspiration"). On image-sharing site Pinterest, certain search terms ("pro-ana") trigger a health warning and support referral. Critics have suggested such measures are more concerned with minimising litigation than harm.
But how much harm do they cause? Analysis of the content of pro-ana sites, published in the American Journal of Public Health in 2010, found the subculture to be complex, with nearly a third of sites containing some recovery-oriented information, and a quarter communicating "very harmful" messages normalising and celebrating purging and starving. In theory, the authors argued, the site's interactivity and sharing of techniques may have "contagious effects on those not yet committed to the behaviours".
A covert investigation of pro-ana sites, published in Eating Disorders: The Journal of Treatment and Prevention in 2007, found that what attracts users is the sympathy on offer, rather than more sensational aspects such as purging tips and drastic weight-loss goals.
"Much pro-ana discussion content is mundane, suggesting its primary function is social rather than informational," researchers Sarah Brotsky and David Giles write. They also found participants overwhelmingly supported the covert identity's declared intention to seek treatment as she exited each online community. They conclude that the dangers of "contagion" of vulnerable but non-disordered eaters may have been overstated.
Emma says pro-ana's virtual solidarity is something she hasn't been able to find in real-world support groups: she likes not being seen, and the ability to have text conversations when she needs them.
She prefers their support to that of professionals she has consulted. "They can be a bit patronising," she says. "A lot of us know what we have to do to get better . . . It's just that I don't seem to have the power to do it. Also, I've never [liked] the idea of paying to have someone to talk to, as much as that sounds a bit silly. It feels like they're only doing it because they have to."
Pro-ana, on balance, has been more good than bad, she says.
Condemnation of pro-ana communities also raises feminist and ethical problems: beating up on already stigmatised young women for finding solidarity with one another can seem like bullying, despite the good intentions of those who want to police the discussion.
Last year, a ground-breaking study of the personal experience of pro-ana bloggers - rather than their content - was published in the journal Health Communications. It found bloggers experienced positive effects of self-expression, catharsis, and social support in coping with a stigmatised disease. They also experienced negative consequences: fear of disclosure and of encouraging disorders.
The researchers, Daphna Yeshua-Katz and Nicole Martins, concluded that, in light of the poor results of conventional treatments for eating disorders - those treated for anorexia have less than a 50 per cent chance of recovering within 10 years, they point out - further investigation of prevailing diagnostic and treatment protocols were warranted.
"Instead, the young [pro-ana] women themselves are blamed for sabotaging their own recovery," they argue. "Our results suggest . . . that the moral panic about the websites might not be appropriate."
Parallels with pro-ana can be found in the fat acceptance movement, which aims to change social and medical prejudices about those with large bodies. Both are trying to break down stereotypes that looking a certain way makes people moral or aesthetic failures.
Like Gay Rights, Women's Lib or Deaf Culture, these are arguably all identity movements that aim to recast as diversity those traits condemned as disease or disability and that are the basis for discrimination.
An Australian study published in the Qualitative Health Research journal in 2011 found members of the "fatosphere" community had improved health as a result of the support and acceptance they found online. If fat acceptance rightly seeks to de-stigmatise the large-bodied, why couldn't the same be true of pro-ana? Because unlike obesity, the experts say, anorexia is a mental illness.
The categorisations of mental illnesses, however, are not like the laws of physics. "Disordered" behaviours can move in and out of the medical-psychological spectrum over time. Radical psychiatrist R. D. Laing argued in the 1960s that schizophrenia might have been a sane reaction to an insane world. Homosexuality, notoriously, was removed from the Diagnostic and Statistical Manual of Mental Disorders in 1986.
If an anorexic adult wants to continue with a severely restricted diet and finds support from an online community, who are we to say that this is dangerous and enabling, rather than empowering?
Ethicist Stacy Carter, who works at the University of Sydney's School of Public Health, says the question of whether pro-ana should be respected or condemned comes down to autonomy. If the anorexic behaviour has its roots in damaging experiences, she says, then it is legitimate to question "whether that person is in a position to make good judgments about how to live a flourishing life".
"If it's true that the very nature of being anorexic is the state of being constantly miserable, then it would make more sense to do whatever you could to [intervene]," she says.
But you also need to think about the side effects of any intervention, she argues.
"If young women are attracted to pro-ana websites, that immediately suggests they need a community they can identify with. So shouting at them about it being bad to be anorexic and trying to shut down the sites seems to miss the very purpose of their engagement with the sites in the first place. Maybe a better to way to think about it is, how can we provide that?"
La Trobe's Susan Paxton points to therapeutic applications that seek to do just that, including an online chatroom run for six hours a week by the Eating Disorder Foundation in Victoria (moderated, however, allowing only "positive" chat), and an app to help those with disorders monitor what they are eating and how they are feeling, with the data sent to a clinician for review.
UWA's Phillipa Hay says a "counter culture" is emerging that includes chat rooms and "therapies that can be delivered ethically over the internet".
But it is not just the technology that enables pro-ana. It is also its uncensored, unsupervised nature.
In the weeks after interviewing Emma, I regularly check her activity on her favoured pro-ana site under her membership name. She's back there most days but hasn't posted a comment asking for or offering support since I first contacted her via the site.
She told me she likes to hide away. I feel my anxiety about her is well-intentioned. But I suspect she feels she's being watched.
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