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From Anorexia Nervosa to Anemia

Josep Martí*

Department of Archaeology and Anthropology, IMF-CSIC, Barcelona, Spain

*Corresponding Author:
Josep Martí
Department of Archaeology and Anthropology, IMF-CSIC, Barcelona, Spain
E-mail:
jmarti@imf.csic.es

Received: 27/05/2015 Accepted: 29/05/2015 Published: 08/06/2015

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Abstract

Anorexia nervosa has been a matter of concern in the Western society for decades. Sometimes people talk about anorexia as a deeply perplexing illness and health experts acknowledge that it is a disorder of a very difficult treatment. Although, in addition to the biological and psychological dimension, people also speak about social factors as possible explanations of the disorder, the fact is that social explanations are generally treated in a very superficial manner. The main thesis of this article is that we can hardly achieve a good understanding of anorexia nervosa without soundly taking into consideration its social and cultural foundations. They are precisely the ones that make many of those who suffer from it understand the eating disorder not as a disease but also as a lifestyle. Thus, it can be of interest to put into contrast that conventional perspective, which conceptualizes anorexia as a disease, as an irrational behavior understood within the old mind/body dichotomy and centered on the individual patient with a view more focused on the social and cultural dimensions. According to this alternative view, we can understand anorexia as a lifestyle (anemia), as a rational (although harmful) behavior that involves a constant and dialectic interplay between Körper/Leib and that grants agency to an anorectic person within a complex framework of social relations and its own semiotic community. Not denying the psychological traits, which often accompany many anorectics and reinforce their life choice such as obsessive (perhaps we could even say passionate!?) behavior or difficulties in emotional expression, this alternative view of anorexia can contribute to better understanding of this kind of eating disorder.

Keywords

Anorexia nervosa; Eating disorders; Body; Lifestyle; Anthropology.

Introduction

Anorexia nervosa has been a matter of concern in the Western society for decades. Since the body is of great interest for anthropology, we cannot ignore the contributions that this discipline can make towards better understanding this issue. In this respect, the theoretical approach of the social presentation of the body [1] may be helpful to us. From the actor’s point of view, speaking of social presentation of the body implies the existence of a conceptualization about (external) aspects of the body, recognition of the big role that the body plays within social relations as well as different strategically premeditated actions concerning this body appearance in the view of personal purposes. If, according to Susan Bordo, we can understand anorexia nervosa as a characteristic expression of our society, or the crystallization of everything that fails in it, rather than an anomaly or aberration [2] it is perfectly suitable to resort to social theory to better understand all that anorexia nervosa implies. A report about anorexia nervosa of the National Institutes of Health in the USA published in 2004 stresses the fact that it is difficult to treat it: “Despite progress in understanding the biologic and genetic underpinnings of these disorders as well as preliminary data suggesting that if treated early the majority of patients do recover, the perception remains that these are untreatable, self-imposed disorders” [3]. In the conclusions of the report it is added that there is still very little research done to come up with an effective treatment, and in fact, this idea that concerning anorexia nervosa we are facing a very difficult challenge is a constant issue in the specialized literature [4]. The conceptualization of anorexia nervosa is closely related to the idea that we have of “body”, and obviously, its treatment will depend on our conceptualization of anorexia. The question is that, if the treatment produces poor results, may it be a consequence of our conceptualization of the body and therefore of anorexia? Without any doubt, in the case of anorexia nervosa, people recognize its social aspects. In fact, there are explanatory attempts of this problem from three different viewpoints: biological, psychological and socio-cultural factors [5]. Nevertheless, when people speak of the social factors, people have in mind what is called the “social environment. Therefore, for example, in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders published by the influential American Psychiatric Association all that is said in this respect is the following: “Historical and cross-cultural variability in the prevalence of anorexia nervosa [6] supports its association with cultures and settings in which thinness is valued. Occupations and avocations that encourage thinness, such as, modeling and elite athletics, are also associated with increased risk” [7]. The ideology of a consumer society, as well as the influence of the powerful mass media, which spreads skinny body images are important reasons that explain the current magnitude of the epidemic among teens. As Abigail Bray wrote, “the idea that women ‘catch’ psychiatric diseases from the media constitutes a form of (scientifically sanctioned) common sense” [8]. But this is not enough. I would even say that it is a very superficial manner of understanding the problem. No doubt that these are powerful reasons but there may be other much more important social and cultural reasons, especially those which concern our own structure of thought. And in this respect, the contribution of the anthropological approach can be very relevant. According to Richard O'Connor and Penny Van Esterik, if modern medicine has so many problems to understand and to treat anorexia, it is precisely for not moving from Cartesian dualism [9] namely: The idea that we have of an “individual” within the individual/society duality. The concept that we have of body, strongly attached to Platonic roots and clearly Cartesian mind/body dichotomy.

Individual - Society Duality

We know that an individual isolated from the rest of the society is a mere abstraction and the very idea of society presupposes that it is made up by individuals. Dealing with the issue “society versus individual” it is often and rightly claimed that it is a false dichotomy since these two separate realities are, in fact, not imaginable. We are speaking then of a duality, a construct that anthropology tries to overcome. It is better to consider the individual and the society as two different aspects of the same reality, losing in this manner their status of independent entities. We can conceive society as spaces of connections in which individuals emerge. Therefore, our attention has to be focused “neither in the individual psyche nor in social structures, but in the interactive processes that take place routinely between people” [10]. Individual and society constitute two inseparable system components, and neither one is conceivable without the other. We can understand societies as interacting individuals in the same way as we can understand the individual as the concrete result of these interacting individuals. The traditional concept of individual - as a kind of closed box- is an ideal image just like that of the homo clausus, which Norbert Elias rightly criticizes (1978: 119). It would be a mistake to think that we really are individuals in all what this word implies. We are "fragments", parts of a whole; that what we are, we are in and with each other. If we believe in the idea of individuals, it is because of an ideology of any kind: social, political or religious. We produce ourselves and become persons through interactions with each other. Identity always means a defined self within a social reality. Are we aware of this fact when we try to understand anorexia nervosa? Are we aware when we try to treat it? Precisely one of the criticisms that has been made about the concept of "body image", which is so important for the conceptualization of anorexia, is that body image discourse rests on a fundamental split between the individual and society [10]. Society is seen as an external force that acts on the vulnerable minds of people with anorexia. This split between the individual and society results in individualistic explanations for women’s anxiety and distress about their bodies [10]. As George Herbert Mead stated, we can’t see ourselves at all without also seeing ourselves as other people see us [11]. For all these reasons, we must be aware that if we speak about the phenomenon of anorexia nervosa as a problem, it is not just the problem of the person who suffers; it is a social problem. That is why it has been said that anorexia nervosa and bulimia are individual solutions to social problems [12].

Dual Conceptualization Of The Body

Today we know that the body is not a purely objective data, but the result of a social and cultural production [13]. As Susan Bordo said, our bodies, just like everything that is human, are constituted by culture [2]. And in the conceptualization of the body, the dualistic idea of body/mind is the one that prevails in our society. Thus, for example, in a book on anorexia we can read: “The conscience is to the body what a radio program is to the receiver. Given that the conscience represents an immaterial and own quality, it is naturally not product of the body or depends on the existence of this. Therefore, it is a mistake to say that the body is ill; what is ill is the mind of the carrier of the disease, even though the state of disease manifests in the body as a symptom” [14]. Thus, the most normal is that, in the case of mental illnesses, people recognize these two different entities mind and body: two entities connected between themselves with what we call "perception". The body is what the individual mind can see [15]. The mind is researched while the body is relegated to the status of a physical object (Ibid.). In this sense the body is something that people have, rather than what people are. Michael Lambek says that in the duality body/mind it is not the case of an opposition between logical opposites (as good/evil) or empirical opposites (as life/death) but also of incommensurables: “I claim, refer not to contraries or opposites, but to fundamental incommensurables in human experience. Incommensurables by definition are not susceptible to measurement by a common yardstick. In this way they are radically different from binary oppositions who are by definition, in the phonological prototype, are relational and constituted by their commensurability. There is no place half-way between mind and body, people cannot be all body or all mind. The mistake of Cartesianism lies not in its dualism, not in distinguishing mind from body, but in assuming that the relationship between them is one that can be definitively and unilaterally established [16]. The ideas of Husserl, differentiating between Körper and Leib [17] the phenomenology of Merleau-Ponty differentiating between body as object and live body [18] and especially the idea of embodiment, as it has been defined by Thomas J Csordas help us overcome the alleged mind/body dichotomy. Through the idea of embodiment, the body is understood not as an object, as it is for biomedicine, but as a real subject of sensations and experiences, as source - therefore– of subjectivity.

Social presentation of the body and anorexia. Anorexia as a cultural behavior

Bearing in mind the need to overcome this individual/society and body/mind Cartesian dualities, the case of anorexia nervosa can be perfectly analyzed within the context of the theoretical frame of the social presentation of the body. By definition, the social presentation of the body refers directly to the expressive dimension of our behavior. That is to say, by the way in which we present the bodies to the others we do not only "do” things to but also "say” things to. In this way we can approach to anorexia nervosa not as a result of an organic or psychological dysfunction, but as a behavior which has to do with the social presentation of the body and which involves a creation of sense; as something that aims to act and to express. From the theoretical perspective of the presentation of the body, I prefer to denominate Ana&mia as what is known as “anorexia nervosa”. This serves us for depathologizing the concept in order to fully understand it in the social and cultural dimension. Ana&mia should not be primarily understood as a disease but as a cultural behavior focused on the desire to achieve and maintain an extremely skinny body. The essential characteristics of this behavior include the fact of carrying out certain procedures in order to have a thin body – more than what is considered healthy - making sure the existence of iron will not increase the weight and to have very demanding evaluation criteria about the one’s own body complexion, always aimed at extreme thinness as an ideal. The case of Ana&mia is characterized by giving a great importance to the social presentation of the body. People place great attention on everything that refers to the general body care or clothing and Ana&mia has obviously to do with body modification. This cultural behavior includes thus certain values as well as specific techniques in order to get a slimmer body, among them those that involve malnutrition, either through deprivation of food or purgative measures. This is a behavior that, like so many other cultural manifestations, may be extremely insane and self-destructive. In this theoretical approach we will leave aside the fact of considering anorexia nervosa as a disease. Whether or not it has to be considered as a disease, is something that falls on health professionals and not to anthropology. But I think it may be of interest to put this possibility into brackets, in order to address anorexia from a different aspect. In this way we can see anorexia through the perspective of determined aspects which are not taken into account enough and which perhaps can allow us to better understand the issue and facilitate its treatment. In addition, I think that the reasons to conceptually take into account this methodological bracket are well justified: First of all, and by now, there is not any solid basis that allows us to think that anorexia nervosa is a disease from a biological perspective [19,20] Even the so called “body distortion”, which is often ascribed to anorectics and that is presented as a clear pathognomonic sign, has been refuted [21,22]. From the emic point of view, anorexia nervosa is not usually considered a disease. The difficulties of its treatment. As I said at the beginning, there is a perception that anorexia is something intractable [3] and this may be precisely due to a problematic conceptualization of anorexia. We also have to remember that diseases are not entities, they are explanatory models [23] and therefore, according to the context, the same phenomenon may or may not be considered an illness. For our purposes, thus, we can discard here the explanatory model that understands anorexia as a disease. The fact that we can understand Ana&mia not as a disease does not mean that many of the people who are following this way of life can not suffer psychological disorders of different nature. Furthermore, although we conceptualize anorexia as cultural behavior, it is clear that this behavior involves an abuse of the body, with serious consequences that may even lead to death, and therefore, we have to talk here of a deeply insane behavior. We cannot be so misguided as to consider anorexia nervosa as cultural behavior when in the medical field it is understood as a culture-bound syndrome, that is, within those kinds of disorders that only appear within a specific society and have a lot do to with culture. We know that culture is ideas, products and actions. In the case of anorexia we find ideas about the high value given to bodily slimness and that through determined actions (controlled eating) an extremely skinny body (product) is achieved. If identity, social order and the need of exchange are three important parameters of the social logics [1] the basic idea that we find in Ana&mia is that “I have to be thin and I follow (strict) rules and norms in order to get my desired body and to attain in this way an advantageous position in the exchange relations with the individuals that make up my social context.” Just as a girl said in a proanorexia blog: “I want to be beautiful and loved by all, that guys pay attention to me, that they love me, I want to be attractive and want to have them all." We are speaking of generally fragile people from the point of view of identity – something obvious in teenagers (with marked body changes). Undergoing rigorous self-imposed norms (regarding food), they seek safety and intend to ensure a privileged position among peers being admired for their body and self-discipline. Understanding anorexia as cultural behavior means taking very seriously all that this implies. Concretely, it means a specific way to do things, according to determined cultural patterns; a specific way of thinking according to determined social constructs; and also, not to be forgotten, a specific manner to be understood within the social environment which pathologizes this behavior. Understanding anorexia nervosa as cultural behavior also allows us to better understand it as a "way of life", which is how most often the concerned people see this behavior. The characteristics of this lifestyle are clearly manifested in the explanations which anorectics give about their behavior and that likewise are thoroughly reflected in the different web sites that support this type of practices. Very often we find the assertion that these people do not consider themselves sick: “Anorexia/Bulimia are lifestyle choices and we feel are not diseases'' [23]. We are talking of a life style which from the anthropological point of view can be understood as a specific case within the broad area of body modification practices and which implies a frame of very specific values such as the ideal of thinness as beauty, the ideal of perfection, self-discipline, sacrifice and effort and social distinction. All these aspects are very clear in a blog where, among 50 different argued reasons in favor of anorectics, it is written: “[anorectic girls] are nice, there are few, they are seeking perfection, dress well, they are different, people envy them...As anorectics know that their social context values their behavior very negatively, in this lifestyle, resistance and cryptic attitudes are adopted that contribute to empower them: "where there is power, there is resistance" [24]. Despite being fundamentally self-destructive practices, they are not nihilistic: "I don't seek death or any of that, if I wanted to kill myself, I could take a gun and my hand would not tremble, but I don't want death, I love life, the perfection, and when I will attain my perfection, I will live and enjoy it.” A lifestyle as drastic as of anorectics often presupposes a break up with family and friends. However, all lifestyles are also related to an idea of community and this idea of community, in the case of Ana&mia, is facilitated by the cyberspace. We can be sure that the current possibilities of creating virtual communities’ constitute an important factor for the growth that this kind of behavior has undergone in the recent years. In these websites, among other things, a sense of community is created, and as it happens in all lifestyles a specific vocabulary is used: Princess, Ana (for “anorexia”), mia (for “bulimia”), a thinspo body, thinspiration, collar bones, thigh gap, binge, throw up, Ana Wannabe (a person who does not have anorexia but wishes to have it). We even find symbolic resources, as is the use of red bracelets for anorexia and violet ones for bulimia, as well as the ritual value given to certain actions which are typical for Ana&mia’s the fact of calorie counting or the vomit in the toilet. In these internet virtual communities messages are exchanged; people give each other tips related to food practices and slimming techniques, tips for hiding Ana&mia practices from family or friends, and also for seeking or offering support. One can speak, therefore, of a true semiotic community where not only determined meanings associated with the body are shared, but also in relation to a very important aspect for the Ana&mia world, as food is. In this cognitive orientation, food acquires a special significance according to the number of calories (people speak about "reverse calories", protein qualities, the fat content, etc.). In the same way, the circumstances accompanying food intake also receive special meanings related to the where, when or with whom the food is taken. The idea of “community” is considerably strengthened when there is a figure of the external enemy. These external enemies are those who do not understand but fight this style of life – family, people close to them, therapists, etc. At the same time, within the social sphere of the anorexia, people often sound critical to society in general, especially to the hypocrisy that involves the fact that while, on the one hand, preference is given to slender and thin bodies, on the other, anorexia practices are demonized: "I give you encouragement to be the queens of this cruel world." "People say that neither the weight nor the complexion matter, but they never put it into practice.” In order to understand what is really anorexia and, at the same time, to facilitate its treatment, it is essential to give the due weight to the semiotic community of the concerned persons. In psychoanalysis, for example, a lot of importance is given to the family in order to understand the reasons that drive a person to anorexia. But on the other hand it is too often forgotten that, especially in teenagers, it is not the family that constitutes their main experiential world but their "community". It is for this community that people want to show a skinny body according to social ideals of thinness. The Ana&mia lifestyle also involves the notion of a deliberately chosen risk. People know the risks they run but they submit them to their ideals. Once I asked a girl who suffered from anorexia if she and the girls like her did not see the dangers of their behavior. She said "Of course they see it, but it doesn't matter for them". Ana&mia has to be necessarily understood, thus, within that broad range of risky activities that are particular characteristics of the young [13] and which often also imply the idea of “transgression”: "Yes, I know that anorexia and bulimia are dangerous diseases, but I also know that Ana and Mia are two lifestyles, that like any other must be respected. All depends on the personal point of view. Take for example homosexuality. How many people believed years ago or even still believe that being gay is being sick? A lot of people think so, but homosexuality it is simply another way of life that deserves dignity and respect; we want to be accepted as well. "I know that it is dangerous, but it is my body, it is my mind, it is my heart: It is me who wants to be on this path without looking back, fighting for my perfection. I can lose everything, but the desire to walk this path is stronger than to be within that entire rainbow surrounding me filled with food and people. I prefer my white and black world that Ana and Mia very kindly have offered to me for life.” The fact that anorexia nervosa focuses on the expressive dimension of culture can explain two of its features: the fact that it is more typical of women and also of middle or upper social classes. In the West, there has traditionally been a tendency to value men’s bodies for their performance and those of women according to their ability to express, something that is also very well reflected in the Western art [25]. This would be consistent with the fact that our society gives more importance to the physical appearance of women than of men [26] “men act and women appear” [26]. On the other hand, if food is not a problem from the point of view of the economic possibilities, i.e., it is basically assured, it becomes part of those cultural elements that can be easily taken into account in order to use them in their expressive dimension. In this manner, "things are said" through the food people take or - in the case of Ana&mia - through the not ingested food. Ana&mia is a body-centered behavior. The strength of Ana&mia is, precisely, that it is inscribed in the body, unlike many other lifestyles. We are talking about a body behavior, and in this sense it is extremely relevant to take into consideration the important Körper/Leib distinction. While people around anorectics - family and health specialists - see an emaciated Körper, with underweight problems or bradycardia among others, for an anorectic person, from the perspective of the Leib, there are many more things that come into play. It is not only important that objectification of the body is manifested in a concrete weight or a specific figure. It is also important, for example, to have the feeling of success which people experience corporally when the so-called "collar bones" are achieved, when the outstanding clavicle or other bones can be clearly felt; or when the so highly desired “thigh gap” is attained and people see how the progressive slimming of the body meets their expectations. All this is also spurred by how people feel the body when they are still far away from their objectives: “An hour ago, more or less, I sat down and felt how my abdomen stood out: it is the worst thing in the world... If I bend to pick up something I feel how my stomach, instead of remaining hidden in my ribs, stands out.” It is a feeling that the same people often qualify as of disgust towards their own body and that it is experienced in a form of a deep bodily concern: "Sometimes I look in the mirror and I feel disgusted towards myself, a true disgust, really.” "Since the day I had my first fasting, I have been overconfident and began to eat again... to eat junk again... And here I am again at 72 kilos... almost the same weight from which I started... Just one month before I begin my holidays on the beach...and I’m still obese, fat, deformed, disgusting and revolting." And always the same SHIT. I am so tired that by waking up, you get up and only think about all this. You go to the bathroom, the first thing you do is to take off your clothes or to lift up the shirt, to lift up the pants in order to see what you look like. Then you feel impotence, an absolute rage...! All the effort served for nothing, the love handles of the belly are still there, the cow legs are still there, the dewlap is growing and remains there, in its place, arms with overhanging flesh which when you move are like gelatin are also still there in its fucking place, all, ALL continues being the same or worse. Precisely, this body as Leib, as a body which is lived from the phenomenological perspective is what another person can hardly capture. It remains in the Körper, the semiotic body as it has also been called. And we cannot forget that from the phenomenological point of view, things make sense especially by how people feel them. It is interesting to compare the current anorexia nervosa with those cases of starvation caused by religious reasons and that we know from the past. What are different in this case are the motivations and values associated with these practices. But in both cases, what is common is the achievement of an exaggerated weight loss that causes significant health problems as a result of a selfdiscipline related to these values either as a denigration of the material body in order to live up to a certain spirituality or to worship determined bodily beauty cannons. What is clear is that as Abigail Bray said; to depreciate women’s abilities to resist the interpellations of the media means to understand the female audience as a weak-minded, docile body. Anorectics are treated or regarded as "silly" or irrational, something that is not true but makes them feel deeply misunderstood and, therefore, they close themselves up and adopt cryptic and resistance attitudes in practice of their lifestyle. In medical publications about anorexia nervosa there is much talk of the symptoms but very little of the personal reasons that can lead to this cultural behavior. More traditional treatments are applied with more focus on controlling than on understanding the "patients": “I know no ‘problem’ as lethal as anorexia/bulimia, given what I have seen with my own eyes and heard tell that is so misrepresented. And those who suffer equally misrepresented” [27]. It is not at all strange then that, as I myself have seen, parents may observe a certain infantilization in their daughters when they undergo a long anorexia treatment. Another interesting aspect to be discussed is to what extent anorexia nervosa has an iatrogenic component. Through what has been called "the cultural construction of authorized clinical reality" [28] Ana&mia, as a cultural behavior, is pathologized. In fact, it has already been stated, that through traditional treatments which pay great attention to body image the unhealthy aspects of this behavior are reinforced. As Gremillion wrote: “Clearly, one of the reasons anorexia is so difficult to cure is because treatment practices re-create forms of bodily control that are already defining features of anorexia” [20].

Conclusions

Among the difficulties to treat anorexia that specialists mention are first denial of illness by the “patients”', second the difficulty in establishing a nexus of trust between therapists and “patients”' and, finally, lack of motivation to change their attitudes. Does it mean that we might be wrong in the therapeutic approach? As it has been written, official discourses about anorexia do not pay due attention to the experiential aspects and values of anorectics, hence the little success of treatments. While anorexia nervosa continues to be managed by medical and psychiatric specialists, social explanations and practices remain on the periphery. On the other hand, concerning treatment of anorexia, the interest in conceptualizing it not as a disease but as cultural behavior is clear:

a. We get closer to the reality.

b. People do not treat the anorectics as sick. This can ensure a greater trust between patients and health specialists.

c. Given that anorectics are not considered "sick" or "crazy", specialists can ask them for more responsibility in the treatment. Agency is better acknowledged.

d. The Ana&mia behavior is rationalized, while being understood as illness; this behavior is rather seen as irrational. And this is especially valued by anorectics.

e. Possible iatrogenic effects are avoided.

Perhaps someone may think that it is not so important to understand anorexia as a disease, a disorder or simply as cultural behavior, given that the problem is there and, in the end, all that we have is the harsh reality of an emaciated body. But we would be wrong thinking this way. The fact that anorexia is or is not understood as a disease involves an important differentiation at the level of social perception and, therefore, affects both the way an anorectic person feels and the way it treated. Emily Martin tells us that certain behaviors that from a medical point of view could be perfectly conceptualized as “maniac” are highly appreciated by our society and they are not understood as pathological. In certain work domains, much importance is given to aggressiveness, hyper-productivity or high creativity In these cases people speak of “passion” in regard to those who exaggeratedly devote themselves to produce; but in the case of an anorectic person, people speak of “obsession”. As Benjamin Paul wrote, "If you wish to help a community improve its health, you must learn to think like the people of that community"[29], something that by the way corresponds to the intrinsic empathy that anthropologist’s work must have. And I firmly believe that this is a fundamental key in order to tackle the problem of anorexia nervosa.

Final Notes

1. The contents of this article are based on the work carried out during the years 2013-2015. I have made participant observation in two public hospitals and one private institution centered on eating disorders, all these in the area of Barcelona. During this time I had the possibility of having interviews with people diagnosed with anorexia nervosa, with their relatives and also with health specialists (mainly psychiatrists and psychologists). Besides this, I also explored internet forums and blogs directly related to the anorexia nervosa. From the theoretical point of view, this article draws from the work made within the research project about the Social Presentation of the Body CSO2011-23718 (Spanish National R+D plan ). The first version of this text was presented and discussed in the 5th International Conference: Social Pathologies of Contemporary Civilisation held in the Erasmus University of Rotterdam, the 30-31 october of 2014. I’m very grateful to Caitlin Trathen for the linguistic revision of the text.

2. See for instance Gremillion, 2003; Warin, 2010.

3. Anthropologists by studying other societies have reached the conclusion that the universal validity of the notion of “individual”, just as we understand it in the West, has to be questioned. Sometimes it is necessary to use the notion of “dividual” or “fractual” (Niehaus, 2002: 190). This person is always incomplete and must be defined by a whole set of relationships.

4. My translation. Actually he takes this idea from Dethlefsen and Dahlke, 1989: 13.

5. Ana and mia are nicknames that stand for anorexia and bulimia. The ana&mia label is often used in underground websites dedicated to anorexia and bulimia and in which this behaviour related to restrictive eating practices is predominantely understood as a lifestyle.

6. My translation. http://www.mismejoresamigasanaymia1.blogspot. com.es/ (Accessed on March 22, 2014).

7. My translation. http://justbreatheanamia.blogspot.com.es/2011/03/50-razones-para-ser-ana.html (Accessed on March 17, 2014).

8. About the importance of secretism in this issue, see: Warin 2010: 83.

9. My translation, emphasis in original. http://www.sigoconana. blogspot.com.es (Accessed on April 11, 2014).

10. My Translation. http://pro-anaymia.blogspot.com.es/ (Accessed on April 11, 2014).

11. My Translation http://pro-anaymia.blogspot.com.es/ (Accessed on April 17, 2014).

12. My Translation. http://luchacontraanaymia.blogspot.com.es/

13. (Accessed on May 11, 2014).

14. My Translation. http://my-cristal-castle.blogspot.com.es/search? updated-max=2008-01-15T19:32:00-05:00&maxresults= 10 (Accessed on April 11, 2014).

16. My Translation. http://www.aveceshealthyavecesana.blogspot. com.es/2013_10_01 _archive.html (Accessed on April 11, 2014).

17. My translation, emphasis in original. http://jprincess-awkward.blogspot.com.ar/ (Accessed on April 11, 2014).

18. My translation, emphasis in o original. http://www. mismejoresamigasanaymia1.blogspot. com.es/ (Accessed on April 19, 2014).

19. See for instance: Bell (1985), Bynum (1988), Lester (1995), Lelwica (1999); and also in present days it is possible to find a relation between anorexia and religious behavior (Banks, 1992, 1996).

References