With all the mystery around Ozempic in pop culture, old-school anorexia seems strangely simple. Perhaps this explains the internet’s fixation with both Ariana Grande and Bella Hadid, the singer and model who have become the unintended public faces of pernicious (alleged) eating disorders in recent years. Grande has become noticeably less grande since the pandemic; she shocked observers with her rail-thin frame during the promotional junket for the film Wicked, and in the past few weeks has appeared on stage, incredibly thin, during live shows. “She literally looks emaciated,” said one fan on X; others accused her of having “choreographed sitting” into her dance routine, presumably to avoid lightheadedness.

Hadid, for her part, has been posting again about her Lyme disease diagnosis. The supermodel was diagnosed in 2012 at the age of 16, along with her mother and brother. Intermittently since then, she has shared pictures of herself stripped to the waist in a hospital bed, covered in electrodes or on a drip. One fan says it’s really because she “doesn’t eat”. Others scour the contents of her fridge, finding only “juice, yogurt and berries”. “It’s heartbreaking to see her battling with an ED [eating disorder] and Yolanda is all to blame,” reads one comment, with reference to Hadid’s former-model mother who is known for encouraging her other daughter Gigi only to “have a couple of almonds” when the then-teenager complained of feeling faint and hungry. Bella Hadid may well be debilitated by Lyme disease, but her physical frailty is hard to ignore. As with Grande, her disappearing body is viral catnip.

Why is skinny “back” in celebrity culture? We must not forget the specific glamour of anorexia, glamour which is most intoxicating to teen girls. The literary critic Elaine Showalter memorably described melancholia in the Romantic period as a “prestigious disorder of upper-class and intellectual men”. You can see why it was thought of in this way: plumbing one’s own misery required both depth and leisure. Happiness is for oiks. Of course, this perception had no bearing on real incidence, save for the crazy-making nature of idleness which may have brought the black dog unto a few sad squires. Sighing was probably just as common in the scullery as in the library. Nevertheless many illnesses have their mythologies, and if male depression was conferred an elite status in the past then the female cognate today is without doubt anorexia and bulimia.

The virtuous connotations of female eating disorders are that sufferers are meticulous, intelligent, disciplined and detached — coolly incorporeal, pensive and stylishly sad. The prototype of the chic contemporary anorexic is Marya Hornbacher, whose 1997 memoir Wasted, published when she was just 23, detailed her teen years in recovery wards, culminating in a brush with death when she weighed just 52 pounds. In the book, Hornbacher describes her illness with borderline cinematic sumptuousness: “I brought a stack of books and a notebook, packs of cigarettes, and sat coiled in a chair in the corner, rubbing my eyes… swallowing coffee… reading Bertrand Russell and John Stuart Mill and Marx.”

Here is this sophisticated teenager, swapping food (lame) for philosophy (rad!) while going through coffee and cigs like a Parisian poseur. Are we meant to interpret her starvation as cool or awful? The ambiguity is deliberate. While Wasted won huge acclaim and became the archetypal anorexia memoir, Hornbacher’s barely restrained sense of her own emaciated glamor compromised its function as a “warning” for sufferers and their families. Instead, it spurned imitation. Another eating-disorder memoirist, Nicole Johns, author of bulimia tome Purge, says fellow patients would try to “smuggle” copies of Wasted into treatment facilities, treating it as a manual. Hornbacher’s tendency to brag, and her undisguised nostalgia for the allure of her illness — as well as the instructional nature of the account, much of which is in the second person (“you will lift the toilet seat, carefully slide your fingers inside your mouth and down your throat, and puke until you see orange”) — made it premium reading material for the aspiring anorexic.

Today, this mechanism has become part of the very wiring of social media. Since the early days of blogging sites — Tumblr, Twitter, Instagram — eating-disorder pages have been as depressingly constant as pornography. “Pro-ana” (anorexia) posters compete with one another for the lowest BMIs; TikTok content creators get around guardrails by pretending that the calorie-counts which accompany images of their meals are “prices”. Bloggers share “thinspo” (thin inspiration) — pictures of themselves or celebrities; they “body check”, meaning that they show off hollow stomachs or wrist-thin thighs for other girls to use as motivation. Because they are famished, they also post obsessively about food. In this they resemble the subjects of the Minnesota Starvation Experiment in the Forties, in which healthy men were put on extreme diets. Over 24 weeks, the men were found to hoard and obsessively read cookbooks. Had these men been given access to Instagram, they too would surely have gorged on images of food.

Celebrities are also part of the eating-disorder internet. Many super-thin stars, most notably Ariana Grande, have asked people not to comment on their bodies — Grande called speculation about the looks and health of others “dangerous”. But asking fans — the source of your income — to pay attention to only the “comfortable” facets of your persona breaks the contract of fame: celebrity means sacrificing privacy, and exposure is part of the bargain. Commenters diagnosing stars from a distance — or even “concern trolling” (posting skeletal pictures of women they’re “worried about”) — may be distasteful, but it is inevitable. These celebrities are, after all, the ultimate beneficiaries of the attention economy and stand to gain even when this attention is negative; Grande’s secrecy around her alleged condition has in fact only increased the intrigue and therefore the coverage.

I have little doubt that Grande’s thinness is, to some vulnerable fans, aspirational. And there is no denying that pictures of these celebrities are being used as “thinspo”. Grande posting body-checking pictures of herself fitting inside a guitar case means an X user called “Skinny B4 Death” will inevitably add her to their starvation moodboard. Hadid, for her part, has often posed in a way which emphasizes a starved ribcage; this could well lead to users glamorizing emaciation, in a grisly echo of Nineties “heroin chic”. To those quick to dismiss this as a feminist fuss over nothing, use your imagination: you may not give a sod about seeing one too many jutting bones, but then you may not be a teenage girl. For them, such images can alter the course of a life.

The public spectacle of Grande’s and Hadid’s emaciation is functioning, in the age of the internet, like a virtual eating-disorder ward: hypercompetitive and dishonest, bragging and furtive. Particularly since their fans are primarily those most vulnerable to eating-disorder content: namely, girls. The result of all this blog-worthy boniness is that the troubled years of these stick-thin celebrities may end up just like copies of Wasted: tucked under inpatients’ pillows, bookmarked at the bad bits, treasured as a guide for how to disappear.

Across the river, in an all-male houseshare, a warren of twenty-something Bushwick bros live amid permanent clouds of vape smoke. In their fridge is scarcely anything: a takeout box half-consumed; glossy chicken breasts thawing in the open air; a White Claw left by some girl. But there at the back is a small cluster of vials with funny names — CJC-1295; BPC-157; semax; MOTS-c. The roommates ordered them on WhatsApp from a warehouse in China; they’ve joined the biohacking gold rush, and delight in boring women at parties with insights on fat loss, boosted sleep, ligament healing and telomere extension. Much of it is experimental; the vials declare them only to be “research peptides”, but the bros believe they are at some frontier, and everything — from their hairlines to their form at CrossFit — can now be optimized. 

What unites these fridge owners is this: peptides. These are substances made of short chains of amino acids; essentially, they are signaling molecules. Many, like GLP-1s, have been approved by regulators and are used by millions of people. Some of these drugs are making it into more user-friendly pill formats: Novo Nordisk’s Wegovy pill was released last month. These kinds of peptides can be prescribed or purchased. Two years ago, a mini culture war began when run-of-the-mill fatties were clearing the shelves of Ozempic to the detriment of “real” patients. 

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Other peptides exist on a very gray market indeed: compounds principally sourced from Chinese labs have extremely limited human data, and they are marketed carefully so as to avoid seizure at borders. These off-label peptides are coveted by young men knee-deep in optimization culture — the looksmaxxers, the bonesmashers, the Hinge no-hopers shooting up growth-hormone secretagogues with the determination of doping cyclists. Clavicular, the 20-year-old streamer who hawks courses to help his followers mog, was filmed injecting his 17-year-old girlfriend with a peptide. This is a young man who thinks the problem with JD Vance isn’t his politics — it’s that he’s “fat”. For these new-gen biohackers, nothing matters more than a defined jaw. 

Until very recently, most people’s everyday interactions with medicine were centered on managing pathology. Meanwhile, the hazy border between pharmaceuticals and cosmetics was the realm of our Manhattan lady’s spenny medspa. But the mainstreaming of biohacking culture has dissolved this boundary — peptides, one way or another, are now available to all. The taboo of using compounds to self-enhance was once comparable to that around plastic surgery: as with invasive general-anesthetic-assisted procedures, the question was always why take the risk? But an injection of Silicon Valley frontierism has transformed peptides from a plausible element of Patrick Bateman’s weird morning routine to a casual addition to the daily life of a young man about town: Minoxidil, peptides, coffee. Their meaning is not contained in physical results — gym gains, better REM sleep — so much as their pseudo-spiritual claim: that biology is not destiny; the body is becoming negotiable. 

To the uninitiated, all this must seem baffling and dangerous. One imagines an elite of glossy, perfected superhumans whose performance and endurance have been tinkered with, leaving the rest of us stuck in a stumpy, unbeautiful, thin-haired underclass. There is something frightening about peptide culture’s Ayn Rand-ness: a brutality, an aggressive individualism that shuns the public good and tramples on the collective. 

The fear might be that peptide culture is the preserve of the rich: it doesn’t help that the initial, and very expensive, release of Ozempic catalyzed an anorexia epidemic among celebrities. And yet the truth is, if peptides are to be agents of inequality, the problem will lie in the asymmetric risk taken on by white- and gray-market consumers. The former can pay more and will be taking better, safer substances under the supervision of medical professionals. Meanwhile, somewhere out there, a poor peptide bro is fighting the worst nausea of his life with only a rudimentary Chinese chat support box to save him.

The New Man of 2026 — and coverage of the peptide craze has tended to code it masculine — is too daring for the glacial normies in the FDA or MHRA. Time is of the essence: just like with crypto, the key is to jump in now. It wouldn’t do to be outpaced by a bigger, faster, stronger league of intrepid chads. This sense of urgency should light a fire under government health bodies, which may end up entrusting their citizens’ wellbeing to a laboratory in Shenzhen. 

Before our eyes, pharmaceuticals are warping from a public-health resource to a consumer luxury. The problem is that the lines are blurred. These compounds might not just give us glossier hair and deeper sleep: downstream, they could secure cardiovascular health, delay frailty, even curb addiction. At what point do these effects become public entitlements to be subsidized by taxpayers? Collectively we invest in childhood vaccines, but we’d never blow state money on anti-aging serums. So what happens when pharmaceuticals invade both categories? Our medicinal morality has scarcely evolved from the age of public sanitation in the Industrial Revolution; preventing, not perfecting, is the responsibility of governments. The decisive variable in whether peptides help general populations is not chemistry but policy. 

In the end this isn’t about the drugs themselves, revolutionary though their manufacturers tout them to be. It’s about a psychic shift in our perceptions of the body, from a constantly degrading old banger which limps through MOTs and is periodically fitted with new wheels to an infinitely customizable kit car that can be souped up at the driver’s will. There’s something of the magic potion about these odd little pens and vials stored in the fridges of those who can stomach the cost and side effects. What remains to be seen is whether, as always must happen in fairytales, these particular potions incur a hidden cost.

Today, 18 months on, there is more discussion of Grande’s body than ever before, driven by her appearance in the movie Wicked (she plays Galinda) and the associated press junket with her and co-star Cynthia Erivo (who plays Elphaba). She appears to be tinier than ever. The Mail called her “fragile”; the Standard called her (and Ervio) “scarily thin”. A friend took her seven-year-old daughter to see the film. “Mummy,” whispered the girl mid-screening in a tone of awe and amazement. “You can see all the bones in her chest!”

But the sport of publicly commenting on women’s figures was supposed to have died along with all the other vicious excesses of the Noughties media. What we now call body shaming used to be a staple of celebrity journalism — not just the bitchy bloggers, but also in newspapers, supermarket tabloids and glossy magazines. “Cellulite”, “muffin tops”, “cankles” and “thunder thighs” were all among the sins that could place a famous woman in Mail Online’s “sidebar of shame” or Heat magazine’s “hoop of horror” (a red circle with which the magazine highlighted supposed physical flaws).

The content creators justified this on the grounds that they were doing their women readers a favour by undoing the mystique of celebrity perfection. “Don’t get us wrong, we love celebrities, but we don’t put them on a pedestal,” said Heat’s editor Mark Frith in 2004. As the cult of size zero grew, celebrity body shaming grew to encompass the “scary skinny” girls such as the Olsen twins and Nicole Ritchie, whose skeletal frames became a matter of prurient concern. The sincerity of that concern can be judged from the fact that it was routinely expressed in the phrase: “She needs a sandwich.”

The ultimate body-shaming concern troll came in 2014, when the ostensibly feminist website Jezebel offered a $10,000 bounty for the unretouched originals of a Lena Dunham shoot for Vogue. “Dunham embraces her appearance as that of a real woman; she’s as body positive as they come,” explained Jezebel. “But that’s not really Vogue’s thing, is it? … It doesn’t matter if any woman, including Lena, thinks she’s fine the way she is. Vogue will find something to fix.” In other words, Jezebel was performing a public service by rooting out photographs of Lena Dunham looking imperfect.

But the language it used was only a sidestep away from the oldest excuse in the book when it came to violating famous women’s boundaries. She wants to be looked at, ergo we have a right to look at everything. It’s just that, in this case, it came veiled in the rising language of “body positivity”: Dunham owed this to her audience. It seemed obvious, though, that Jezebel’s true interest in the originals was the hope that Dunham would look terrible, and that a lot of people would click through to see the full horror.

Jezebel had miscalculated. Dunham accused them of making “a monumental error in their approach to feminism… It felt gross.” And the public mood was more with her than it was with snarky upstart posters. When the pictures proved to have been only lightly edited, the whole thing fizzled out in a haze of disapproval. Magazines and websites pivoted to celebrating bodies rather than judging them. Glamour put the model Tess Holliday (UK size 26) on its cover in 2018; Cosmopolitan featured plus-size yoga instructor Jessamyn Stanley in 2021, with the tagline “This is healthy”.

The turn against body shaming was politically coded: as reactionaries like Jordan Peterson were calling plus-size models “not beautiful”, so the imperative for feminism was to take the body-positive side. That meant, in practice, a taboo on commentary about bodies entirely within feminist-inflected media. As most women know, there’s little more grinding than other people giving you their unsolicited verdict on your figure, and any conversation that takes place on the internet is effectively within earshot of the subject. That went for the thin as well as the fat: “Why is skinny-shaming OK, if fat-shaming is not?” asked recovering anorexic Emma Woolf in 2013.

“There should be no implicit or explicit assessment of any kind,” said the feminist philosopher Kate Manne earlier this year, while promoting her book Unshrinking: How to Fight Fatphobia. For her, even the term “body positivity” didn’t go far enough, and she instead proposed a concept that she called “body reflexivity”. “My own mantra became, ‘My body is for me, your body is for you.’ Our bodies are not there for comparison or correction or consumption. One’s own perspective on one’s body is the only one that matters.”

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Put like that, this seems a clear-cut point of principle. It is also an impossible, unachievable ideal that supposes perfect individual subjectivity. But humans are not like that. Even Kate Manne is not like that. In her book, she writes about the fat influencers whose work she finds particularly encouraging or impressive. Clearly, she has an emotional reaction to their bodies which is inspired by identification with them. She experiences their bodies, in part, as something for her.

In any case, the placing bodies beyond discussion has never been a universal feminist aim. Other intellectual strands have sought different ways of talking about the body instead, trying to move beyond objectification and towards an understanding of the body as a political entity. In Susan Bordo’s 1993 book, Unbearable Weight, for example, she attempts to understand disordered eating in women not as an individual pathology, but as “a ‘crystallisation’ of particular currents, some historical and some contemporary, within Western culture”. This is a long way from Jezebel’s fishing expedition for kompromat on Dunham; but it’s equally remote from the belief that bodies are only ever “for themselves”.

Even when body positivity was at its height, it was an imperfect revolution. Concepts such as “wellness” allowed the dread “diet culture” a covert return; then the rise of semaglutide as a weight-loss treatment placed bodies firmly back in the realm of legitimate topics. How could we not talk about the fact that famous people were changing shape so rapidly and dramatically? But Grande is not a case where anyone would suspect her of medical intervention. She’s been in the public eye since she was 15; she was thin then, and she’s thin now.

The difference is that now, she is alarmingly thin. For this to be addressed publicly is undoubtedly not easy for Grande. “It’s a knife when they dissect your body on the front page,” she sings on Sympathy is Like a Knife with Charli XCX, and there is no way to have this conversation that isn’t painful to the person being talked about. But to not address it would be perverse, and the duty of care here is not only to Grande’s feelings. It is also to the young women and girls (many of them pre-adolescent) for Grande represents an ideal of adulthood.

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Eating disorders are socially contagious and competitive. Grande insists that her current physique is healthy, but she does not look healthy, and anyone attempting to replicate her waifishness is unlikely to end up healthy. That needs to be acknowledged — not as a judgement on Grande, and not with goading comments about sandwiches, but as fact. To pretend otherwise, creates a situation where young women and girls can self-starve and no one is able to acknowledge it happening. That cannot be the correct outcome.

Talking about bodies is a precarious business. Grande is right that we should be “gentler”. Bodies deserve care, and there is no care in the engagement-baiting judgement of the click mill. There is equally no care in the phoney belief that Grande’s body affects no one but her. And even if that were true — can the only acceptable response to watching a young woman fade be to chide anyone who notices it happening? Let’s talk about Ariana Grande’s body. Gently. Let’s hope she’s OK.

An obdurate Leadbeater seemed to think her bill’s wording excluded this disturbing outcome in principle. Assisted suicide on the NHS, she insisted, will be reserved for the terminally ill, with a stipulation that “a person is not to be considered to be terminally ill only because they are a person with a… mental disorder”. But as Chelsea Roff, the lead author of the anorexia evidence pointed out, the disease is — by definition — a mental disorder with devastating physical effects. In particularly severe and prolonged cases, a doctor might well diagnose the case as hopelessly terminal with recovery impossible, in which case eligibility for an early exit would be nearly assured.

This would be a mistake, though an understandable one. In fact, with anorexia, you can only say with confidence that recovery genuinely was impossible and further treatment futile, if and when the sufferer actually dies from the disease. Until then — doctors’ illusions of omniscience aside — you don’t know for sure. Some will seem to be at this point and then later recover; for occasionally, even entrenched anorexia can loosen its grip, and fuel-starved minds start to change. If a sufferer opts for assisted dying, then, we will never know for sure whether the same could have been true of them.

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Indeed, it is potentially worse than this; for it seems that a diagnosis of terminal illness in the case of anorexia might have a rigidifying effect on a sufferer’s intention to give up on life. This is one between-the-lines reading of a case history offered by US medic Jennifer Gaudiani concerning Alyssa, an anorexic who was eventually euthanized at her request. In an email to Gaudiani four days before her death, Alyssa insisted that her course of action was not being “pursued in isolation, but rather in the context of being in Hospice care following a terminal [diagnosis] of anorexia (i.e., estimated six months or left to live)… In my individual case, death was inevitable. I clearly understood my prognosis and accepted this. I saw [medically-assisted dying] as an opportunity to select a specified time and circumstances for my death.”

Gaudiani is herself supportive of assisted dying for so-called “terminal” anorexics; but relatively few general campaigners for assisted dying positively want this sort of outcome, as such. Still, the logic of their own position inexorably corners them into it. For, though it is often unnoticed, the assisted dying movement is a collaboration between two radically different ethical ideals, whose goals have only surface compatibility. The state-enabled deaths of willing anorexics is just one side effect of the underlying tensions.

First, we have the Freedom Lovers. These are campaigners whose buzzwords are “my choice”, “my right to die”, and the like. Freedom Lovers are steeped, whether knowingly or not, in a liberal tradition which emphasizes freedom from interference from others in various personal domains. Their pronouns of choice are usually I/me/mine. They tend to think of death-seeking as a wholly private matter.

The vision of the Freedom Lover can be seen most clearly when away from the morally murky domain of assisted dying, considering suicides of the unassisted kind instead. Possibly the most hardcore Freedom Lover there ever was, was anti-psychiatry psychiatrist Dr Thomas Szasz. A Hungarian-American, he wrote many books railing against the coercive nature of the medical establishment. He thought that if you decide to kill yourself, you have a right to noninterference from everyone else, even in the case of severe mental illness. Any reason to end your life is a good one as long as it is yours, and any attempt to stop you is an infringement on personal autonomy. Inspired by the pejorative “Big Pharma”, he once coined the concept “Big Suicide Prohibition” — though for some reason it didn’t catch on.

Alongside Freedom Lovers, another archetype is also heavily involved in pro-assisted dying campaigns. I’ll call her the Altruistic Helper. Whereas the Freedom Lover is, at base, a suicide permitter, the Altruistic Helper is a suicide enabler: not so much interested in leaving people alone to do their thing, as positively helping them do it. Her preferred language mentions “compassion”, “humanity”, “mercy”, and “quality of life”. Her preferred pronouns are not first- but third-personal.

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Unlike the Freedom Lover, she does not think of the value of a life as subjective, or that any reason to go is a good one, as long as it is yours. Some circumstances are more deserving of death than others. Though sometimes reticent to spell this out, it seems clear that Altruistic Helpers have firm views about what should happen, objectively, when a life contains so much suffering that it is not worth living. In that case, they think, its owner should be helped to die; it’s the morally correct thing to do.

While she pays due deference to the presence of consent to the assisted dying process, unlike the Freedom Lover the Altruistic Helper is not massively interested in it for its own sake. Rather, she simply takes consent as good proxy evidence for the presence of unbearable suffering in a person’s life. Her background thinking seems to go: if you have a terminal diagnosis, and you are deliberately seeking an early exit, the only possible reason for which you could be doing this is that you are suffering unbearably. (Indeed, Kim Leadbeater seems so sure of this fact that in her proposed process, the candidate won’t be asked about her personal reasons for seeking death at all.)

To say that the Freedom Lover and the Altruistic Helper are strange bedfellows is an understatement. Strictly speaking, what should interest the Freedom Lover according to the logic of his ideal is decriminalizing private voluntary acts of suicide assistance, organized contractually between individuals. You want to die, for whatever reason; I want to help. It’s all voluntary, and nobody else’s business to interfere.

Yet thanks to the Altruistic Helper’s input, they tend to get something else entirely: a huge state-sponsored machine, involving thousands of healthcare employees, policies, and supposed safeguarding constraints upon who can access the service. Uber-Freedom Lover Szasz knew this, and was critical in his writing of assisted dying procedures, viewing them as constraining of personal autonomy. When he broke his back, aged 92, he killed himself alone a few days later.

Another weird feature of the awkward collaboration between these ethical archetypes is that the Freedom Lover can’t really justify why terminally ill people already able to kill themselves on their own, if wished, are deserving of state-sponsored medical assistance to help them do it. Though unpleasant to dwell on, many already have this freedom, as the example of Szasz demonstrates. It is perhaps why Freedom Lovers tend to focus so heavily on paralyzed or otherwise incapacitated people in their motivating examples. In contrast, the Altruistic Helper has no trouble explaining why terminally ill people who ask for death are deserving of state assistance, however mobile they are. Namely: they are clearly suffering too much, and so it is the right thing to do.

The anorexic with suicidal intentions — for all we know temporarily — ends up as collateral, falling between the two stools of these ways of thinking. Anorexia is a relatively anomalous condition, hard to fit into familiar binaries of active cause versus passive effect. The mind produces a willed behavior with devastating effects on the body. The physical effects of anorexia are not exactly voluntary, given the role of persistent, near-automatic habits of approaching food; but not exactly involuntary either, and certainly not involuntary like those of cancer or arthritis.

Effectively, anorexia acts as a Rorschach test for assisted dying campaigners. To a committed Freedom Lover, the behaviors associated with anorexia, including accompanying suicidal intentions, look active enough to count as an expression of free will — at least, assuming mental capacity has first been established, as was the case for Alyssa. (Purists like Szasz may not even require this.) Those who are Freedom Lovers by instinct are not particularly inclined to go out to bat for the exclusion of people from assisted suicide provision who appear to have rationally decided it is their time to go. To say otherwise would look like a kind of interference in personal autonomy, and Freedom Lovers can’t have that.

Meanwhile, the Altruistic Helper is likely to frame the terrible physical suffering produced by severe and prolonged anorexia as something that happens to a sufferer, rather than something she has any part in actively causing; an irrevocable, settled fact that merits a compassionate release into peaceful oblivion. As intimated earlier, Altruistic Helpers tend to see a person’s firm desire to die, accompanied by physical affliction, as an indirect indication that the amount of suffering present is objectively too hard to bear. This is supposed to be what justifies helping him to end his life. If Helpers were to admit that the physical torment of a severe anorexic, as awful as it is, is not enough to make an assisted death justified, they might just have to rethink their whole model.

And so, like the Freedom Lovers but for different reasons, Altruistic Helpers are also unlikely to argue forcefully for the exclusion of suicidal anorexics from an assisted dying service. Depending on who is looking, these troubled women and the occasional man will be seen as captains of their own ships or helpless victims of the storm. And either way, an artificially hastened exit from a sea of troubles will be theirs for the asking.

I think of her often, mainly because I — along with others in our anorexia treatment group — was mean to her. The severity of her illness both irritated and frightened us. It felt as though she was parodying us, representing sickness with all of the person taken out. The only fierceness she exhibited was with regard to food rituals: scraping out bread rolls, then rolling crumbs between her fingers, making Slim-a-Soup, then tossing three slops down the sink before taking one sip of the rest.

L’s diagnosis was the same as ours, and in some cases, her body weight was not dramatically different. Nonetheless, she seemed to inhabit a different space entirely. Like us, she might have been afraid of gaining weight, but she was beyond fearing recovery, that half-resisted, half-desired transformation of self. For L, the very idea seemed ridiculous. Everything had been burned away, every remaining muscle, every trace of her identity, to the point where one would have had to build an entirely new person in her place.

I am sure that today L would have met the criteria for a diagnosis of terminal anorexia nervosa. In 2022, US eating disorders clinician Jennifer Gaudiani, along with Joel Yager and Alyssa Bogetz, published a paper recommending palliative care and assistance in dying for anorexia sufferers who “simply cannot continue to fight”. (Bogetz, a sufferer herself, died before the paper’s publication.) Here in the UK, new NHS guidance has been issued for patients with severe and enduring eating disorders (SEED). The “SEED pathway” includes taking the focus away from “full recovery or weight gain” and offering “palliative care interventions focused on pain and symptom management”.

Many have reacted to this news with horror. I am horrified too, yet when I think of L, it gives me pause. The final weeks of her life were appalling. She had no peace, surrounded by people who could not accept her as she had become. Three days before she died, she was still going through the pantomime of “group lunch”, when we would sit round a table and act as if we could eat like “normal people”, in preparation for “afterwards”. Rather than prioritise her comfort, we challenged her over the breadcrumbs she’d flick across the table. We each told tales if we saw her hiding food, nominally concerned at her “lying to the group”, but also resentful about how her rule-breaking might reflect badly on us. Her last days on Earth were torment; she was forced to pretend — for our sake, not hers — that she had a chance.

I am against normalising the concept of terminal, incurable anorexia. At the same time, I know, both rationally and from experience, that some long-term sufferers do become unreachable. I am sure that offering them palliative care would lead to a better, more humane death. But it’s a position that makes me feel callous and compromised. If we start to redefine particular anorexia cases — especially if we start talking about them as “terminal” — we need to consider our long history of bad attitudes towards the illness.

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There have been significant changes in public and medical interpretations of anorexia over the past 40 years. Many of them have been positive. When I was first diagnosed in the mid-Eighties, three things were generally known about the “slimmer’s disease”: Lena Zavaroni had it; Karen Carpenter died of it; non-famous sufferers were selfish, vain and attention-seeking. This was the environment in which women such as L and I first received treatment. In 1986’s Hunger Strike, Susie Orbach described Eighties treatment programmes as “predicated on conflict with the patient and her very difficult set of behaviours rather than on engagement with her and her feelings”.

My first hospitalisation was in 1987. I was force-fed and, until I gained weight, denied “privileges” — getting out of bed, going to the toilet alone, receiving books and letters, having conversations, even having the light on. I was, it was made clear to me, a bad person whose “performance” of illness was inconveniencing everyone else. I was 12 at the time. Looking back, I tend to think of what happened as formative, turning what might have been a relatively short illness into a state of long-term alienation from the body. Similar things, I suspect, may have happened to L. We were shrews in need of taming.

I would never wish to see the return of such attitudes. Coercion traumatised us and for the most part, it did not work. Old-style force-feeding usually targeted sufferers who had reached a stage of severe physical decline, little attention having been paid to earlier, psychological symptoms. Today, there is greater focus on early intervention, which has far better outcomes. There are evidence-based treatment models, such as Maudsley Anorexia Nervosa Treatment for Adults (Mantra), which provides structure and long-term support. Anorexia diagnoses have increased significantly over the past 50 years, as have hospital admissions and the length of hospital stays — in contrast with decreases for other severe mental illnesses.

However, the mortality rate for anorexia remains the highest for any mental illness, at around 5.1 deaths per 1,000 person-years. Treatments are better informed and less likely to cause trauma, but have not necessarily improved for those furthest down the line. It’s here, I think, that the much-needed backlash against viewing sufferers as “wilful” may have had an unintended consequence.

There is far more compassion for anorexia sufferers now. We tend not to call them spoilt brats in need of a slap and a sandwich. But when I read works such as Hunger Strike, I cannot help feeling that the way in which we have resolved what Orbach called “the conflict” has not been through engagement so much as through retreat.

In recent years, I have noticed a drive to emphasise the (slight) genetic component to anorexia. The Guardian columnist Gaby Hinsliff has been explicit about the exculpatory potential of this, portraying it as liberation from “the idea that sickness must be someone’s fault, or that they could get well if only they chose to snap out of it”. In tandem, I have seen an increase in the portrayal of anorexia via metaphors such as that of the “Evil Friend Ana” who takes control of an innocent individual. The Beat website, for instance, includes a post on “Ana” versus “the real me” in which the sufferer describes herself as “a girl possessed”. But anorexia is not like schizophrenia; the voice you hear is your own.

I don’t think for a minute that anyone can “snap out of” anorexia. However, I feel that it is profoundly unhelpful to depict sufferers are having no agency, and to downplay the cultural, familial and political aspects. To insist, as I do, that anorexia is political is not to reduce it, but to recognise that eating, gender and the body cannot be understood outside of their social and historical context. Hatred of one’s own body, and of the act of putting food inside it, does not “just happen”, even if it seems like a bizarre invasion. I only really began to understand the factors that led to my own madness when I was in my forties, years older than L ever became.

The concept of terminal anorexia legitimises this idea of invasion, as though some bodies are simply infected with uninhabitability. But it has arisen at a time when many of the triggers of bodily alienation are more obvious than ever before. Sexual abuse; pornography; the diet and cosmetic surgery industries; the idealisation of underweight bodies; the objectification of pubescent girls; the belief that sexualised bodies represent inner identities. None of these is trivial. They might not be the things you are actually thinking about when you have anorexia, but I simply do not believe that anyone is born pre-programmed to reject their own body. It is a learned thought pattern.

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To be clear, I am not proposing that anorexia, for all its symbolic potential, constitutes some well-thought-out rebellion against an oppressive society. As anyone who has had anorexia knows, it is not intellectually interesting as an experience; it is, for the most part, boring. You might appear unlike your growing, developing peers, but when you enter group therapy, you find that your symptoms match those of everyone else. You are in no way original.

I used to think there would be more dignity and less shame in viewing my own anorexia as mysterious and inexplicable. Thinking this way made recovery even more difficult: how can you recover, if none of it is really in your hands? “Terminal anorexia” seems to me the logical end point of denying the moral, political, and relational aspects of the disorder. It might make it easier to forgive the dying patient — to not hate and punish them — but it also denies society’s complicity. And once we say that anorexia has a terminal manifestation, can we ever unsay it? Once it becomes embedded in our understanding of what anorexia is, don’t we risk accepting that women such as L were never for this world?

And yet, in refusing to accept a terminal diagnosis, what do I ask of sufferers such as her? For them to hang on in there and try not to have a seizure in the occupational therapy room until the entire world gets fixed? In rejecting both the treatments of the past and the proposals of the present, I might seem to be wanting the worst of both worlds: neither forcing sufferers to live nor helping them to die. I know that a third option, helping them to live, is not always possible.

Nonetheless, I think we can distinguish between treatment programmes that focus on maintaining comfort rather than promoting weight gain, and ones that actually use words such as “terminal” and “palliative”. This might seem a subtle difference, but it matters. There has to be a middle ground, whereby showing compassion does not require us to abandon the principle that no one should be dying of anorexia at all. When L was dying, we treated her badly. To us, she was all illness, no person. I wish we had been better, but acceptance of the dying person should not come with acceptance of anorexia as a terminal disorder. It isn’t — or, if it is, it is only because we have made it so.

While some of those students may have been merely flirting with the condition, they were canaries in a very dark coal mine. All too many of their peers were undertaking life-threatening calorie restriction in great earnest. Anorexia was already known to be the very deadliest of all psychiatric ailments. (Wanting to be anorexic, then, is like pining to contract necrosis.) In the Nineties, my natural ghoulish voyeurism inspired me to read several books about obsessive self-starvation, the best of which was Jenefer Shute’s harrowing novel Life Size.

So surely this month I jumped at the chance to read Hadley Freeman’s Good Girls: A Story and Study of Anorexia? Beginning in 1992, the columnist struggled for many years with the eating disorder, for which she was repeatedly hospitalised for months on end. Yet before diving into what proved a compelling and forthright memoir, I resisted. Honestly? The topic felt dated. Because as a prestige diagnosis, anorexia has been replaced. With trans.

Although Freeman spends half a chapter on the overlap between the two afflictions — both are “rooted in the belief that if you change your body, you will no longer hate yourself” — throughout her account I began to notice other intersections.

Both neuroses are clearly communicable. Ever since a preoccupation with thinness took off in the Sixties, eating disorders have soared, making the more recent insistence that anorexia is more of a heritable genetic proclivity than a cultural contagion dubious. From the Seventies onwards, an accelerating number of young women have got the idea to express their discontent through debilitating hunger from lavish media coverage, and one another. In kind, since 2010 the number of teenage girls referred to the Tavistock Gender Identity Development Service increased by 5,000% — making claims of a purely genetic explanation equally iffy. Both these afflictions are social confections. Although tales of people who starved themselves or passed for the opposite sex exist in the historical record, eating disorders and transgenderism on a mass scale are recent inventions. Collectively, we made these dire maladies up.

Freeman identifies her “trigger” at 14 for dropping an alarming amount of weight as a single moment. Sitting beside a prominently bony classmate in gym class, Freeman asked, “Is it hard to buy clothes when you’re so small?” “Yeah,” the girl replied. “I wish I was normal like you.”

“A black tunnel yawned open inside me,” Freeman writes, “and I tumbled down it, Alice into Nowhereland. ‘Normal.’ Not ‘slim’, not ‘thin’—‘normal’. Normal was average. Normal was boring. Normal was nothing.”

Nowadays, there’s ostensibly no such thing as a norm. In Left-wing jargon, the clunky “norm” words — such as “cis-heteronormative” — are pejorative. A fifth of Americans under 30 identify as LGBT-whatever. Never mind that Eric Kaufmann has documented the large proportion of supposedly bisexual young women who don’t engage in actual same-sex coupling; today’s young people adopt the label of sexual atypicality the way earlier generations wore crocodile-logoed Lacoste shirts. As Freeman notes, normal is “nothing”. Not only heterosexuality but, increasingly, contentment with your natal sex is uncool. According to the report, 12% of millennials identify as either transgender or gender-nonconforming, compared to 6% in Generation X.

Both self-starvation and transgenderism guarantee elevation to a perceived social elite. At least in the minds of some anorexics, being immune to the temptations of crisps and biscuits that seduce mere mortals induces an emotionally nutritious sensation of superiority. Freeman portrays her fellow sufferers in hospital as competitive with one another over who eats less, as well as picky about how grimly skeletal one must become to qualify for admission to their rarefied circle; the same rivalry is readily located online. Public slow-motion suicide inevitably secures outsize attention from terrified parents, worried teachers and concerned physicians. (Freeman claims that anorexics don’t aim to look thin; they aim to look ill.) With its plethora of frenetic exercise rituals and strict internal rules surrounding food, being anorexic can readily evolve into an identity, attachment to which makes recovery still more difficult. A blandly healthy weight threatens the loss of knowing who you are anymore.

Coming out as trans likewise greatly increases attention from schoolmates, teachers and a whole industry of therapists, endocrinologists and surgeons. In a single syllable, “trans” likewise seems to offer a readymade answer to who you are. Freeman tells us that “when an anorexic says, ‘I don’t want to be fat, I want to be thin,’ they are saying, ‘I want to be other than I am, and what I am is unhappy. I want to be someone else.” Clearly, transition to the opposite sex makes the same statement: I want to be someone else. But is becoming someone else really an option?

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Especially since girls came to dominate boys in paediatric gender clinics 3:1, both forms of dysmorphia often hit the same population: suggestible, insecure adolescent girls with a fragile sense of self who are desperate to forestall all that womanhood entails: painful periods; vulnerability to rape and pregnancy; sex, often portrayed in ubiquitous internet porn as female humiliation; and fat. For some anorexics, their refusal to grow into women is implicit; when girls take puberty blockers, their refusal to become women is explicit. Having suffered the physical indignities of mature femininity for over 50 years, I don’t entirely blame them.

Both diagnoses have significant intersections with autism, anxiety and depression, making patients susceptible to a tangible-seeming solution to a generalised discontent. Both populations mistake self-annihilation for a route to enlightenment and rebirth. Both populations seek to salve psychic torment by renouncing the body, the trans child through reconfiguration, the anorexic through evaporation. Both brands of patient embrace the recognisably religious practices of self-abnegation, redemption through suffering and purification via repudiation of the flesh.

It’s in the social sphere where the disorders part ways. When self-starvation was still a hot topic last century, it might have conferred a measure of cachet, but few parents these days would boast that their child is anorexic. I’ve a niece who’s suffered for years from anorexia, and my brother and his wife have been at their wits’ ends. The experience of having a child who refuses to eat is abundantly one of helplessness and despair. Ditto many trans parents — but not all.

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For the paediatric gender clinic whistle-blower Jamie Reed testifies that in America’s liberal enclaves, having a trans kid has become a prestige diagnosis for many parents — one far preferable to the passé status of having a child who’s plain old gay. Reed identifies the root of the problem as another plain old: homophobia.

Yet two distinctions between disordered eating and transgenderism are signal: diagnosis and treatment. In its latter stages, anorexia is visually conspicuous. While anorexics are often duplicitous, starving to death isn’t subtle; it’s not a secret you can keep for long. Freeman was hospitalised because her low weight was measurably dangerous. Yet according to current medical orthodoxy, diagnosis of transgenderism is purely subjective. The condition has no observable physical symptoms, no objective correlative. If I tell you I’m really a man, you have to take my word for it. The status is therefore unfalsifiable, the population of patients prospectively limitless.

As for treatment, anorexia is universally acknowledged as an illness. Doctors regard this potentially fatal form of dysmorphia as a psychiatric ailment that must be arrested and resolved. Not so transgenderism, which is often celebrated, if not beatified as a state of higher consciousness. “Gender-affirming care” doesn’t treat the illness but indulges the patient’s delusions to the hilt. Rather than coach a child to reconcile with reality, clinicians twist reality to reconcile it with the disorder. Anyone who dares describe the bizarre and biologically baseless conviction that one was “born in the wrong body” as a mental health issue is tarred as a transphobe. Were teenage anorexics treated anything like trans kids, they wouldn’t be encouraged to finish their dinner, but rather abjured, “You’re right: you’re fat! Your true self is even thinner! You will never rise to sit at the right hand of God the Father Almighty until you completely disappear!”

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Anorexics negotiate the universal human challenges of finding identity and purpose by shrinking their internal world to a simple commandment: don’t eat. But true anorexics can never be thin enough. Freeman describes a rivalry between anorexia ward residents over who’s been “tubed” — the gold standard of really having made it as an anorexic, because the very last medical resort is force-feeding. Thus the obvious goal of severely restrictive eating is, however hazily conceived, death. Meanwhile, before this morbid conveyor belt reaches its inexorable end point, anorexics undergo hair loss, the breakdown of internal organs, osteoporosis, and mental disarray. Fellow starvelings may whisper competitive encouragement on those websites regulators are always trying to shut down, but at least no one in authority is urging that, if a cadaverous anorexic just loses another 15 pounds, her body and her deep, innate inner being will finally match up.

Conversely, we’re implicitly dangling the promise that on the other side of transitioning to the opposite sex — or feigning transition, since inborn sex is written in our every cell — all a young person’s problems will be solved. Being trans is now a misguidedly easy-seeming shortcut to knowing who you are. But I’m betting that as an identity, being surgically mangled and hormonally discombobulated rarely goes the distance. Moreover, the physical price of buying this false promise of turning into a butterfly is stupendously high: sexual dysfunction, infertility, surgical complications and infections, and the side-effects of powerful medications for life.

What these conditions have most in common is being dreadful answers to the questions that inevitably torture young people: who am I, what makes me unique, what makes me loveable, what do I want to achieve, why does just being alive seem so hard, am I the only one who feels so dejected, what does it mean to become a man or a woman, and is there any way I can get out of growing up? The responsible adult’s reply to that last one must be a gentle but firm “no”.

“You should do the baby-led approach,” my friend said.

Baby-led weaning was coined in the early 2000s, and it advocates that, instead of parents spooning food into their baby’s mouth, they let the baby take the lead by feeding themselves, with parents putting a boiled piece of broccoli, say, or a small cup of hummus on the high-chair tray, which the baby can eat with their fingers. Baby-led weaning became so popular that the baby-led approach has expanded to all areas of early parenting, with baby-led sleeping, baby-led walking and baby-led potty training. Baby-led parenting, in other words.

I embraced the baby-led approach with enthusiasm that was really relief. Hell, I didn’t know how to do anything with these babies – I was just some idiot who put their nappies on the wrong way round every time. How marvellous I could delegate all complicated decisions to my infants! Now they wouldn’t scream at me anymore when I tried to make them do something they didn’t want, ie have a nap. The babies would be in charge.

This did not work out as well as I’d hoped. Baby-led weaning was fine. Baby-led sleeping, however, meant that none of us slept at all. It turned out that my babies were even more clueless than me about how they should be raised. And so, I returned to attempting to get them on a schedule, which they didn’t love, and it wasn’t always fun for me. But eventually, all three of us were sleeping at night.

The first generation of kids who grew up with the baby-led approach are now in their late teens and early 20s, and we are currently living in a baby-led world. Young people have always believed that they know better than the older generation, and now the older generation agrees with them. Middle-aged and experienced editors working in journalism and publishing live in fear of printing something that might displease the twenty-somethings who work in their company’s digital and publicity departments. Parents defer to their teenaged children about the correct languages to use and opinions to hold.

Some teachers even capitulate to the teenaged bullies in their class: last month, the Times reported that a girl in a London private school “was surrounded by up to 60 students who screamed and spat her” after she questioned gender ideology. “Teachers were initially supportive but withdrew their backing after the other sixth-formers accused the girl of transphobia, and the school ended up apologising for not maintaining a ‘safe-space’ in the sixth form,” wrote Nicola Woolcock, the paper’s education correspondent. This girl, ‘Kate’, was interviewed by Julie Bindel for UnHerd last week and she described overhearing her favourite teacher apologising for Kate’s “terrible, hateful behaviour”. Kate, who had only recently left hospital where she was being treated for anorexia, ended up leaving the school.

Babies are tyrants. If they don’t get their way, they cry, they scream as if the world is ending and no compromise is possible. Two babies screaming together, I can tell you from experience, is a nightmare. A pack of them is unimaginable, so I have some sympathy with the teachers at Kate’s school. Anyone who has ever raised a toddler might find the now regular Twitter meltdowns when someone’s employer hasn’t done exactly what they wanted strangely familiar. This is part of the reason the phrase “baby-led” is so alluring: no parent wants deal with a screaming tantrum, and no employer does either. So much easier to let the kids lead the way, even if it does lead to a Lord of the Flies-type scenario, with the adults fearfully letting the kids dictate the norms, as appears to have happened at Kate’s school.

Younger generations have always looked for ways to differentiate themselves from the stuffy old farts who came before – their parents, in other words – while also seeking an identity that confers upon them a set of ready-made beliefs and a supportive social group. This has become much harder with the dissolving of traditional barriers between adults and young people; parents chase social media likes as passionately as their children, the kids are listening to Harry Styles and Kate Bush, just like their mum and dad. In previous decades you could be a punk, or a skater, or a goth. For the current young generation, it’s being a social activist, and the changing parameters in discussions about race and, in particular, gender have become the defining generational divide. Telling your mum off for using the wrong words is great way to prove that she’s old and passé, even if she does still go to Glastonbury. A lot of good has come from this: today’s teenagers are far more clued up than we were in the Nineties, when jokes about disabled, fat, BAME and gay people were pretty much par for the course in any stand-up show and school playground. But a lot of deeply weird shifts have emerged from this, too, and all of them are due to us now living in a baby-led world, where the grown-ups are too scared to say “No”.

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Baby-led doctoring, for starters. In the appallingly sexist but undeniably revealing documentary, What is a Woman?, provocateur Matt Walsh interviews American paediatric professor Dr Michelle Forcier, who is dressed in a toga and talks in the soothing, beatific voice of a cult leader. She says that children are ready to be put on medical treatment to change gender “when they ask for it”. By “medical treatment”, she means Lupron, which is now used as a puberty blocker on gender non-conforming children, but has been used in the past, Walsh rightly says, to chemically castrate sex offenders. Forcier wrongly insists that puberty blockers “don’t have permanent effects”, and ends the interview.

Forcier is not an outlier. Trans activists now argue that confused four-year-olds should be seen as analogous to trans adults. Not very long ago, I received an email from my children’s nursery to say that a three-year-old who I’ll call Daisy was now a boy and should be called Robert. As it happened, my three-year-old had, that same morning, informed me he was an astronaut, but it hadn’t occurred to me to tell anyone (or NASA), and that’s because children’s identities are mutable. They are still discovering who they are, and that’s as true for three-year-olds as it is for 13-year-olds. By now, I’ve received several emails from parents I vaguely know, telling me their child — always under 15, invariably female — is trans and now goes by a new name. Those parents are, of course, only trying to support their child. But it is not supportive to publicly lock a child into an identity when, in a week, or month, or year, they will likely be a very different person.

In March, the Cass Report, an independent investigation into the quality of care for gender dysphoric young people in this country was published. It found that treatment by the NHS’s specialist Gender Identity Development Service had become mired in ideology, with clinicians too scared to raise concerns about rushing children into changing gender, or asking why girls are disproportionately now identifying as boys, lest they be accused of bigotry. If even doctors are too scared to press the brakes on unhappy children diagnosing themselves, what hope for parents?

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Discussions about gender are often described as “toxic”, and that means they are characterised by tantrums and threats from activists — again, arguing tactics that will be familiar to parents of teenagers and toddlers alike, and yet that does not diminish their effect. Parents have been terrorised into buying their unhappy teenage daughters binders to suppress their breasts because ignorant and bad faith organisations have told them — without any evidence — that not doing so will push their children towards suicide. Similarly bosses of liberal organisations have allowed feminists to be muffled and denounced so as to avoid censure from young activist employees.

Adults in their 40s and 50s — my generation — remember what it was like when we were teens. Many of us cringed at the words our parents used: “the blacks”, “poofters” and worse. We tried to tell them not to use those words, but there wasn’t the embarrassment then as there is now about being a bit bigoted. An adult didn’t gain anything, really, from being what was called then politically correct and what is now called woke. Like I said, things are different now, and that’s clearly a good thing. But in our rush to not repeat the mistakes our parents made, too often we have forgotten that, as well as loving and accepting our kids, it is our job to guide and safeguard them.

I was talking to a friend recently about a mutual friend whose daughter has said she is a boy, and so her mum bought her a chest binder, and I said how sad I found that. My friend was shocked by my sadness.

“But what would you do if your daughter wanted one?” she asked.

“I’d ask her what she thought she could do as a boy that she can’t do as a girl, and I’d ask if she wanted to be a boy, or did she want to be different person,” I said.

“But it’s the daughter’s choice,” my friend said.

“It would be her choice if she wanted to self-harm. But I wouldn’t buy her the razor,” I replied.

I don’t know if I’m right, but, like Kate, I was a very unhappy adolescent girl who was treated for anorexia. So I know a little about unhappy and confused adolescent girls, and how much we attack our own bodies to express that unhappiness. I also know what it’s like to be a desperate parent who just wants their kid to stop crying, to be happy and healthy and safe, and to feel like I’m a good parent who listens. The baby-led approach is an expression of that because sometimes (often) we don’t know what’s best for our kids, especially when it comes to a new issue like gender. But guess what? Your kid doesn’t know either, and nor, it seems, does anyone else who is supposed to safeguard them. Our kids aren’t breaking down barriers, they’re rock climbing without any safety ropes, and we’re encouraging it. It’s time for my generation to grow up, and be the adults.

Kate, the pupil in question (whose name we have changed), contacted me on social media. She had seen my condemnation of Jones’s attempts to, in my view, discredit the story and wanted to tell it in her own words. In any case Jones was wrong: her school couldn’t be named for legal reasons — and the children couldn’t be identified. So we meet in central London. She seems wise beyond her 19 years and remarkably articulate: she gives the impression she reads Dostoevsky and Socrates for fun.

“Announcing it via Twitter — that was vindictive,” she says of Jones. “Finding the school — think how much harm he could do to its reputation. If it was ruined, how could it do better in future? He seemed convinced it was just a case of high school bullying that was contrived by a bigot to victimise herself.”

She goes on to tell me what happened, pausing often to compose herself. A politician who sits in the House of Lords visited the school to give a talk on their campaigning for LGBT rights. It was compulsory for the Sixth Form to attend. This peer was dogmatic from the very beginning, claiming that trans people are denied human rights and suggested that the House of Lords is shot through with bigotry. Kate was “disconcerted” by the speaker’s “righteous denunciation of her peers as irredeemably transphobic”. So, after careful consideration, she decided to ask a question relating to how the definition of “woman” differs between critical theory and biological reality.

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When Kate asked about how to achieve productive consensus when there are such opposing views, the peer accused her of reducing the issue to semantics. “I said, ‘I respectfully disagree’, and thought that was the best place to leave it.” At this point, though Kate didn’t realise it at the time, one of her fellow pupils ran out the room crying.

Afterwards, Kate heard several students talking about “transphobia”, and saying that Kate had caused them real harm. Later, the allegations grew: some claimed Kate had caused trans students to consider suicide. When she went to collect her bag from the locker room, she encountered the head girl, who treated her coldly. Then, a number of students circled her and started calling her names: Nazi, bigot, fascist, transphobe, homophobe, racist, cunt.

“I felt their spit on my face,” she says. Shaking, she broke out of the circle and ran, only to fall to the floor. One student, in distress, ran after Kate to ask if she was OK. And later, the Head of Sixth Form asked the students who had berated Kate: “How could you do this?”

But Kate’s ordeal was far from over. Arriving at school the following morning, she found her desk covered in printouts of trans flags, each emblazoned with the text: “Trans right are human rights”. The day after, the other sixth-formers staged a spontaneous “Trans Day of Visibility”, some students coming to school dressed in pink, white and blue, the colours of the trans flag. No one had told Kate about it.

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An investigation was opened into the alleged bullying of Kate, and the Deputy Head interviewed several of the students, including Kate. Then, a few days later, Kate came into school only to overhear her favourite teacher apologising to her fellow sixth-formers for focusing on Kate and allowing others to be distressed by her “terrible, hateful behaviour”.

Later, a second investigation was launched, “to justify the reaction of the girls”, says Kate — one that focused on her allegedly “‘provocative’ history, going back five years”.

Feeling distressed after what she felt was public condemnation, Kate self-harmed on school premises. She was then asked to stay home for several weeks, “because I was seen as a danger to myself and to other students”.

Eventually, Kate returned to school. She was keen to get on with her studies; she’d previously had to retake her GCSE year because she’d been hospitalised with anorexia. However, she was made to sit in the library, separate from other students, “just surrounded by books and my own thoughts”. The isolation had a terrible impact on her mental health. “I started to see food as completely unappetising again.” But when she asked to go back into school properly, she was told that she had “distressed” the students for too many years, when all they had done was look out for her.

Then she decided she’d had enough. She cleared her locker, walked out of the school, and never went back. Kate is continuing her studies online and is on course to begin university by the time she’s 21. “I will feel as if I’m a mature student,” she laughs.

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It’s clear that some of Kate’s views on trans issues have developed as a result of her personal experience of anorexia. “I couldn’t help but hear the anorexic mentality reverberate in conversations of gender dysphoria,” she says. “Both aspire to reach an idealised, elusive form of the self. Both are driven by a desire to control one’s reality.”

She had experienced some “very traumatic health incidents” as a teenager; after spending a year in hospital, aged 13, being treated for her eating disorder with other girls from very different backgrounds, Kate re-entered the world “fundamentally changed”. Her school had also changed. It had become involved with Stonewall and there were several girls identifying as non-binary or trans. But the school had always been more liberal than establishment, and Kate was fond of many of her teachers. It was these positive experiences that made her feel she could question, out loud, whether she was a “bad person” for doubting trans ideology.

“Why would they turn on me so viciously?” Kate wondered.

“I’m not denying the validity of medical transition as a means to stifle anguish,” she adds. But there is a difference, says Kate, between transitioning to control one’s perception of oneself, which relies on external social validation, and doing so to alleviate profound psychological distress. “In accepting the constraints of biological reality you’re assuming both a burden and responsibility. I empathise with that. It must be unfathomably difficult.” During the height of her anorexia, she felt that “I would kill myself if I gained weight”.

Kate told me didn’t know what she wants to do with her life, but that she “can’t wait” to get to university. She is nervous, though, about entering another place of education in today’s climate. She fears that, these days, “there is no forgiveness for those branded with the damning suffix of ‘–phobic’”.

Suffering often means suffering alone and it was this that first inspired the creation of awareness days and, as inflation inevitably happens with these things, weeks. So, although not everybody might be aware of it, this week is Eating Disorders Awareness Week, one of a diverse array of awareness weeks on the awareness week calendar.

There is clearly some value in such events. It is good for people to know that they are not alone and to have easy access to resources that might be of help. Still there are aspects of them — specifically those concerning mental health — which annoy me.

As writers like Jonny Gleadell have argued, modern discourse around “mental health” can pathologise quite normal behaviour. “Many issues have become medicalised,” Gleadell says, “No matter how far the symptoms are from meeting the threshold for diagnosis.” Professor Joël Billieux and colleagues suggest in an entertaining essay on overpathologisation that by the loose standards of some mental health scholars, we could diagnose them with “Research Addiction”. The market for shouty headlines about crises and epidemics ensures that this kind of sensationalism finds a home.

At its worst, this can provide a smokescreen for miserable, fixable material conditions. As students have been confined to their grief holes in British universities, for example, doing seminars online and thinking of the money they will have to spend for the privilege of having been there, we have heard a lot of talk about protecting their “mental health”. But this threatens to conflate a symptom with a disease. One trainee psychiatrist wrote, “I’m struggling to find the mental illness here. There’s no DSM code for being locked in a cupboard. CBT worksheets aren’t going to let students hug their parents again.”

Another problem is how simplistic the messaging can be. There is no doubt that British institutions need a renewed focus on eating disorders as experts warn of a “tsunami” of urgent referrals, and there is no doubt that the loved ones of people who might succumb to anorexia, bulimia et cetera should be aware of warning signs. But the valuable goal of communicating this demands some awareness of their complexities. “Awareness” is not an instant revelatory experience. It takes time and thought.

Some years ago I suffered from bulimia, which developed into anorexia — growing serious enough that I was dangerously underweight and experiencing awful cold, even in June, and obsessive, monomaniacal thought and behaviour. I stubbornly told myself and everybody else that I did not have a problem — accepting that I was sick and had to seek recovery only after working out that I was more emaciated than Christian Bale had been in The Machinist.

I do not believe there was any single cause of this. It would be marvellous, as a writer, to latch onto some unkind remark or anxiety-inducing image that set all of these events in motion — but it would be a lie. I had struggled with my weight for years, but I had struggled with everything: school, university, relationships and, above all, myself. The food I ate, or did not eat, was one thing I could control.

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When I read about eating disorders in the media, though, everything comes back to body image. That one factor is zeroed in on out of a whole spider’s web of causes. A recent well-intentioned BuzzFeed article addressing EDs among men talked about “body insecurity”, “unrealistic body standards”, “ideal paradigms” and “the pressure to have Captain America’s washboard abs and bodies devoid of an ounce of body fat”. Endless think pieces  debate the effects of social media, and fashion models, and the nebulous concept of “diet culture” on people’s sense of self.

As Hadley Freeman wrote in a perceptive article, “Eating disorders are the only mental illness that people still assume is caused by something identifiable and external.” Of course, that does not mean these things are insignificant. Body image plays a role in eating disorders and it is influenced by the people we look up to. Did it help me that one of my favourite albums was the Manic Street Preachers’ Holy Bible and its song “4st 7lbs”? Probably not. But did Richey Edwards take a cheerful and confident young man and make him ill? Absolutely not. The problem is what these articles do not mention. Body image is one factor but it is not alone.

Genetics could be another. According to a 2020 article in Science, “reports showed that 50% to 60% of the risk of developing anorexia was due to genes.” Different reports have claimed that anorexic people often have a specific kind of metabolism that makes them more vulnerable to mental illness. Professor Cynthia M. Bulk, a veteran researcher into eating disorders, suggests, “the processes in the body that normally regulate metabolism, including weight regulation, may be malfunctioning in anorexia nervosa patients.”

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This is all interesting, though not much help to people who have the conditions. But there are other psychological factors at play. Are we witnessing a dangerous rise in young people seeking treatment for eating disorders more because of Captain America and Instagram or because their lives have been upturned by a pandemic which has thrown their education, their social lives and their future into chaos? I suspect that it has more to do with the latter. Food restriction, in such a bewildering and depressing time, is one thing that is in their hands.

I do not want to poeticise illness here. At some point an eating disorder becomes far less of an exercise in self-control than an exercise in addiction. In anorexia, for example, one’s mind and one’s metabolism create a vicious circle in which the more underweight one becomes, the less one is capable of appreciating the need for sustenance. It is as if one is a car in which the emptier one’s petrol tank becomes, the more petrol one sees on the fuel gauge. That is why treatment of the most severe cases focuses on getting people’s weight up. Physiological changes tend to be a precondition for psychological changes. It is a terrible illness.

Still, even if one rejects the idea that someone with an eating disorder controls their illness more than the illness controls the person with an eating disorder, that does not mean one should be so reductionist as to shrink a complex phenomenon down to a single element. That is unhelpful, and more than a little patronising.

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It would be unfair to expect attempts to raise awareness of mental health problems, or any health problems, to reflect their every nuance. After all, these campaigns are not aimed at turning average people into experts, but making them more mindful and empathetic. Yet just as I have the nagging sense that a lot of the discourse around depression is aimed less towards people suffering from its clinical varieties and more towards people suffering from gloom, listlessness and self-doubt, I have the nagging sense that a lot of the discourse around eating disorders serves less to illuminate the lacerating self-abuse of mental illness and more to illuminate sad, common dissatisfaction with oneself. That dissatisfaction is not trivial. But it is not the same.

If you know someone who might be slipping into an eating disorder it is good to be aware of what they eat and what they say about themselves, and their relationship with food. It is also good to be aware of everything else in their life and how it might be contributing to their state of mind. Otherwise, one might miss the forest for the cold, bare winter trees.

If you’re worried about your own or someone else’s health, contact Beat on 0808-801 0677 or beateatingdisorders.org.uk

She was not allowed clothes for months, and was forced to wear a humiliating anti-rip smock. At one point, she was prevented from obtaining sanitary pads. “I literally had blood running down the insides of my legs.”

Later, she talked in more hopeful terms about the start of her “recovery journey” after being moved to a Coventry hospital, although she worried that it was far from her home in Wales. Soon after arriving, another post detailed the horror of being restrained in seclusion, where she spent the best part of two days: “It’s scary, suffocating, closed in. Utter panic runs through my veins and frustration bubbles, boils and overflows,” she wrote. “I want to cry and scream and shout and kick and sometimes do. Overwhelming. Terrifying. Darker than dark. That’s what it feels like to be in there. Locked in.”

She accepted it was for her safety but concluded by saying: “Sad really to think that life has come to this.” Now those words feel even more poignant — for they were her last ones in public. Claire took her own life at that hospital, despite supposed one-to-one monitoring under her care plan.

An inquest last year reached an open verdict, after concluding that long-term use of seclusion and segregation had intensified the troubled 25-year-old’s mental decline; while staff levels, reduced observations and other care failings “probably caused or contributed” to her death.

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This hospital was run by Cygnet, a fast-growing firm that is owned by the biggest healthcare operator in the United States. It insisted patient safety was “top priority” and claimed to have tightened procedures after Claire’s death. Yet the Care Quality Commission (CQC), the official watchdog that had raised concerns before the tragedy, later revealed a second death at the unit last year. On Christmas Eve, it threatened the hospital with closure, placing it in special measures and shutting down one “dirty, unhygienic” ward after inspectors found unacceptable levels of self-harm, staff shortages and routine use of restraint.

Now the CQC has gone further. It has, unusually, published an investigation report condemning the firm’s leadership for systemic failings rather than simply identifying units giving cause for concern. It criticised over-use of physical restraint and segregation, and highlighted more assaults and self-harm compared with services run by other providers. It also pointed out “active deception by hiding incidents and low staff numbers from the CQC and family members”, along with lack of strategy and safeguarding supervision. Statutory checks had not been made to ensure directors and board members met the “fit and proper” person test for their roles.

Once again the firm insists it is taking steps to improve its services and denies any complacency. It defends itself by saying it has “some of the most acute patients that other providers may not be able or willing to support”, effectively blaming patients for its own failures. “Would you ever hear people on a cancer ward described as ‘acute patients’ or having ‘complex needs’ as a cover for providing substandard services?” responded the Rightful Lives campaign.

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Bear in mind this is the company that ran Whorlton Hall, the Durham hospital where 10 staff were arrested last May after an undercover BBC Panorama team exposed cruelty and abuse towards people with autism and learning disabilities. The 17-bed hospital was subsequently closed. Another seven Cygnet services were found to be ‘inadequate’ or threatened with closure by the CQC — more than any other private psychiatric care provider.

The firm was criticised also at an inquest last year into the strangling of a woman by a fellow patient that exposed staff failures. The jury concluded that if all the correct observations and procedures had taken place there was “possibility that death may have been prevented”. A nurse was dismissed after the killing for gross misconduct.

This is a catalogue of appalling failure. It should spark fierce debate over exactly what is going on behind the locked doors of secure psychiatric hospitals as rapacious private firms muscle in on the lucrative trade in locking up human beings. I have spoken to several patients and families who have told me of disturbing experiences inside Cygnet units during my year-long investigations into abusive detention of people with autism and learning disabilities. Latest figures show 2,190 such people remain incarcerated due to lack of support in the community, exposing shamefully-persistent political failure, despite endless pledges to end this scandal.

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Like a small handful of other private operators, Cygnet has grown steadily amid an intensifying mental health crisis and thanks to increased state funding. It has taken over three rivals since August 2015, so now runs 113 facilities in England. Its most recent annual report boasted how it “did business’” with 228 NHS purchasing bodies, helping operating profits rise to £45 million in 2018. It almost doubled the remuneration package handed to its highest-paid director — most likely to be chief executive Tony Romero — from £508,000 to £953,000 while total spending on “emoluments” for directors surged from £912,000 to £2.4 million.

This is the ugly face of capitalism. There need to be far tighter controls on these fat cat firms. Matt Hancock, the health secretary, should stop mouthing platitudes and finally take action to end this cruel exploitation of vulnerable people. Even as I write this sentence, another email arrives from a despairing parent over her distressed daughter, stuck in segregation yet still able to swallow a latex glove. Strangely the Left, too, is largely silent on such profiteering from failure and misery. The unfortunate citizens stuck in cruel secure units where they are violently restrained, forcibly sedated and held in lonely isolation are second-class status.

Yet this issue does not just revolve around abysmal social care failures, nor even dismal private operators funded at great cost by taxpayers. (It can cost up to £730,000 a year per person in these secure units). For this latest CQC report raises a more profound question over our mental health system: why is our nation sending more and more of its citizens into secure psychiatric hospitals in the first place?

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A few weeks ago I visited Trieste, which pioneered a very different approach to psychiatric care based on opening doors and embracing human rights. It dates back half a century to the actions of an iconoclastic psychiatrist named Franco Basaglia, who argued “freedom is therapeutic” as he unleashed 1,200 patients locked up in a huge asylum complex above the coastal city. His work — part-inspired by controversial ideas circulating in British psychiatry — led to an Italian law blocking admissions to public mental health units, which were replaced by beds in general hospitals and smaller community facilities. Five years ago, the country went further and phased out forensic mental health units.

His legacy in Trieste is impressive and moving. One British expert told me before I went that if he was suffering mental health problems, he would want to be treated in that city — and it was easy to see why. Teams of medics rely on discussion and persuasion, backed by local services open day and night, instead of chaotic institutions filled with stressed patients and overloaded staff. “We have open doors everywhere,” said Roberto Mezzina, who has just retired as director of the city’s mental health services.

“Our belief is anyone can live freely in the city with the right support. We have proved this over many years. There is nothing positive about coercion. There is no study showing it has worked anywhere in the world.”

The Trieste model is based on respect, treating patients with mental health struggles in the same way as if they had any other kind of sickness. Remarkably, this genial psychiatrist told me he had never used physical restraint in his 41-year career, relying instead on often-exhaustive negotiations with patients based on listening to concerns and understanding their anxieties. He joked about use of ‘gelato therapy’, taking stressed patients out for a walk, coffee or ice-cream to help calm them down.

Contrast this with our own country: the brutal techniques of restraint were used almost 100,000 times in English units in 2016/17, leaving more than 3,600 patients with injuries. Teenage girls have repeatedly told me of their terror at being held down by teams of adults, then forcibly injected with sedatives after being stripped.

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It is naive to expect CQC inspectors to stamp out abuse in 22,949 adult social care settings, 234 independent mental health units and 55 NHS mental health trusts on their flying visits, even if the watchdog has belatedly gained a few teeth. But ponder a tale I was told by Mezzina in light of all the abuse exposed in our mental health system.

When he arrived as a young doctor in Trieste, he was tasked with helping to discharge the final batch of institutionalised patients, moving most back to live in the community. Their lives quickly improved as their rights were restored. Yet the impact on the nursing team was just as strong: they stopped abusing their charges after seeing their humanity. “I call this parallel empowerment — power should be bottom up and challenge everyone. You cannot change the system otherwise.”

Herein lies the key to what has gone wrong with our services. If you remove rights from people and detain them in secretive units, this can foster abuse — especially in a culture that looks down at people with autism, dementia, learning disabilities and mental illness. Yet we have seen rates of involuntary admission almost quadruple since the landmark 1983 Mental Health Act with a significant surge in recent years, which leads to increasing reliance on those private places run by multinational operators. Detentions rose another 2% last year alone. A debt-funded model relies on constant flow of fresh patients. Now more than half of mental health patients admitted are on compulsory basis — and almost four in 10 patients are then subjected to coercive measures such as restraint, sedation or segregation within four weeks of their enforced entry.

Politicians love to talk of ending the stigma of mental health problems. But our fear-ridden society views patients with such difficulties through a prism of danger. This demeaning attitude has been inflamed by reaction to high-profile murders by people with psychiatric problems, then intensified by funding shortfalls, slashed services and chronic shortage of beds. The result is that Britain, like some other countries, has ended up with a service that revolves around risk analysis rather than effective or more sympathetic treatment, with private firms soaking up gaps in services.

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This approach is ethically and medically flawed. It is also fiscally foolish. Trieste’s open-door approach ended up costing only 39% of its old asylum, which needed more staff to guard patients round the clock. The most recent review of our mental health laws — sparked by a 40% rise in use of coercion over a decade — was scathing about people being detained for public protection when better and cheaper alternatives are available. Published 13 months ago, it highlighted the lack of respect for patients and how the environment in which many people are held “is now anything but therapeutic”. Many of those incarcerated people with autism and learning disabilities end up in a far worse state with severe post-traumatic stress.

These failings frequently prove fatal. A BBC investigation found unexpected deaths in mental health services rose 50% between 2012 and 2016, while I know of one hospital where 34 patients have died over the last nine years, highlighted by a father desperate to free his daughter.

Among the most appalling recent cases was that of Connor Sparrowhawk, a teenager with autism and epilepsy who drowned in his bath in 2013. Afterwards it emerged that the award-winning Southern Health trust had not even bothered to examine the deaths of some 1,000 patients with autism or learning disabilities, sparking a national review and showing once again the dismissive attitudes towards such people that plague our society.

We need far more than slogans to solve this health crisis, with an adult debate on everything from provision of decent, well-funded community services and rapid expansion of autism testing, especially for girls, through to candid discussion of the complex issue of euthanasia for suffering individuals seeking to end their own lives. But this discussion must be rooted in respect, not simply revolving around the detention of troubled citizens in secure units, out of sight from the wider public.

This is not simply an issue of privatisation, poor care and political failure. It is about power. And it is about the most fundamental of human rights — that of freedom from state oppression. Claire Greaves knew that she was severely ill, but wrote movingly on her blog of her dream to deal with her problems as an outpatient backed by a supportive mental health team. She wanted to work in a bakery, go to ballet classes and have a baby. It was her vision of “a life worth living” that she never managed to attain. So how many more must die before we see the real problem in our society?