I’m sure not how much time the average health law enthusiast spends on Instagram, but as a rare opportunity to see health regulation in real-time, I’d encourage logging onto the site, which curates content based on user profiles and by tags, and searching for the following tags; #thinspo, #thighgap, and #eatingdisorder. The site will either return no results, or will present the searcher with a warning message that “Posts with words or tags you’re searching for often encourage behavior that can cause harm and even lead to death” and encouraging the user to reach out for help, though the flagged content is still accessible if the user clicks-through. #thinspo (short for another neologism, ‘thinspiration’) is exactly what it sounds like – images designed to inspire an individual to restrict their diet, and exercise to attain what will generally be an underweight physique. Many social media sites have enacted similar bans on content as a reaction to the role that online communities can play in promoting eating disorders.
As a suite of illnesses, eating disorders have severe, and sometimes life-threatening medical complications. Anorexia nervosa has the highest death rate of all psychiatric illnesses; bulimia carries severe medical complications associated with starvation and purging including bone disease, heart complications, digestive tract distress, and even infertility, and EDNOS (eating disorder not otherwise specified) while carrying subclinical status in DMS-IV, carries similar levels of eating pathology and general psychopathology to anorexia nervosa and binge eating disorder, and a similar degree of danger to physical health to anorexia. Instagram had been criticised for its inaction in the face of an explosion of pro-eating disorder community activity on its site after Tumblr and Pinterest enacted bans on ‘thinspiration’ content, at which point many users migrated to Instagram’s platform. Five years on from the initial ban, some terms, like #starve and #purge will display the above warning message; other obvious tags for the pro-eating disorder community, like #skinnyinspiration and #thinspire attract no warning message and display images of emaciated women, romanticizations of eating disorders, images of individuals destroying food, and in line with clinical understandings of how eating disorders manifest themselves, images of self harm.
Further, the ban has been criticised for allowing the vocabulary of tags associated with pro-eating disorder content to proliferate rapidly. Researchers at Georgia Tech found that the initial 17 terms banned by Instagram spawned over 250 new terms, generally deliberate misspellings to avoid detection by the website, like #thyghgap, #anorexique and #thinspooo. Even more disturbingly, the same study found that the lexical derivatives had 15% more comments and 30% more likes than the original tags did. This example illustrates some of the barriers to effective regulation of speech online, where the rapid development of vocabulary allows targeted communities to avoid capture, and render bans chronically under-inclusive.
More complex again is how the law should, or even can respond to the issue of pro-eating disorder communities that lie off conventional social media sites. Individuals grappling with an eating disorder can find wonderful communities of recovery support online, and many have attested the importance of online community and ‘recovery Instagram’ in helping them recover from some of the most dangerous mental illnesses, which makes sense considering how visual concepts of body image and self-confidence are. Moving deeper into the internet and past the social media platforms, there are thousands of pro-eating disorder forums and discussion platforms which fall into the unregulated grey area of the internet performing the reverse function; providing individuals with ready-made communities of individuals also suffering from an eating disorder, but for whom support means glamorizing disordered patterns of eating, endorsing crash-dieting, sharing tips on avoiding detection by loved ones, providing one another with coaching on minimizing food intake, and in some cases competing with one another for weight-loss, and posting images and their measurements for group affirmation or disapproval to fuel purging cycles. Many blogs and forums have a quasi-spiritual element, where ‘purity’, and concepts like ‘the Ten Ana Commandments’ are invoked, solidifying the structure of the community around a higher law that differentiates community members from the outside world.
The obvious harms involved prompted France’s lower house to approve legislation banning the promulgation of pro-eating disorder content, where violation carries a prison sentence of 1 year and a fine of up to €10,000. The global regulation of images and media that romanticizes, encourages and glamorizes eating disorders worldwide has slowly picked up pace. In addition to the ban on ‘pro-anorexia websites’, France, Israel, Spain, Italy, Brazil and India, as well as California have enacted bans for ‘ultra-thin’ or ‘underweight’ models, generally using BMI measures to determine if someone is chronically underweight, and hiring an individual who doesn’t meet the requirements can attract huge fines for fashion houses and advertisers. Some jurisdictions have also regulated photograph retouching, requiring that images where a model’s body shape have been changed are marked as such. Even more powerfully, Getty Images, the largest stock photo agency in the world, announced recently that they will no longer accept submissions where the body shape of the model has been manipulated.
While photoshopped images and the glorification of starvation-level skinniness persists in the outside world, the particular damage that exists in online communities really can’t be overstated. One of the wonderful and dangerous things about the internet is how a number of sites, taken together can form a patchwork version of reality where individuals can form relationships, engage in social communities, curate a version of themselves and of their lives in a way that is true, and honest, but also often uninhibited by underlying social pressure to categorise disordered eating as problematic. The real challenge is articulating a line between content that allows sufferers to feel like part of a community and better come to terms with their illness, and content that supports the negative impulses that are part-and-parcel of eating disorders. At a minimum, the regulation sphere should recognise the ineffectiveness of continuing to host harmful content behind a warning wall. Individuals who are primed to search for pro-eating disorder content are unlikely to be discouraged from accessing their desired content by being confronted with a pro forma message about the danger that eating disorders create, given that these are individuals whose disease insulates them from societal norms around health already, who compartmentalise the dangers associated with their disease, or who are unable to control the deep-set impulses that are a characteristic of eating disorders. Instead, researchers like De Choudhury and Chancellor at Georgia Tech recommend that social media platforms modify the recommendation system to show users ‘content that is very different from what they are looking for’, promoting pro-recovery images when individuals search for terms that are generally associated with eating disorders, and manipulating the image feeds of individuals whose content flags eating disorder concerns by redirecting them to images from the recovery community, where tags like #foodisfuel, #selflove and #EDwarrior replace the community-building language of ‘The smaller your waist, the weaker his knees’. Engagement like this may interrupt the reality-warping power of eating disorders in the same way that promoters of Photoshop bans hope that the shiny sticker proclaiming ‘retouched photography’ will.