To the Bone, which arrives on Netflix Friday, is a mostly unremarkable film about anorexia, in that it follows the model of virtually all existing films about the subject. Ellen (Lily Collins), a young white woman from a privileged but dysfunctional family, is anorexic. In the narrative arc of the movie, she’s admitted to a treatment center, where a charismatic doctor (Keanu Reeves) essentially tells her to choose life. She gets better, and then worse. All this aside, there’s one notable difference between this particular movie and its manifold predecessors: It debuted at Sundance, not on Lifetime.

If nothing else, the movie’s platform is a hopeful sign for sincere treatments of anorexia, since features tackling the subject have historically been sidelined to  the schlocky genre of movies made for television. There’s The Best Little Girl in the World, a 1981 movie produced by Aaron Spelling that starred Jennifer Jason Leigh as a 17-year-old cheerleader and ballet dancer who develops an eating disorder. That movie was based on a book by the psychotherapist Steven Levenkron, who treated Karen Carpenter; after Carpenter’s death from anorexia in 1983, the film received a boost in the public eye. The Karen Carpenter Story, a lightly fictionalized movie about Carpenter’s struggle with the illness, even aired on CBS in 1989.

There’s 1994’s For the Love of Nancy, which, like To the Bone, featured in the main role an actress who’d previously recovered from anorexia (Tracey Gold). There’s 1996’s When Friendship Kills, and 1997’s Perfect Body, and 2001’s Dying to Dance, and 2003’s Hunger Point. More recently, Lifetime aired Starving in Suburbia, a 2014 film that expanded the confines of the genre by including  a new scare factor: pro-anorexia (colloquially known as pro-ana) websites, which supposedly lure unsuspecting teens into starving themselves by encouraging anorexics to share their own tips and tricks.

The fact that such a glut of movies exist about anorexia—compared with only a few about bulimia, and virtually none at all about binge-eating disorder, or Other Specified Feeding or Eating Disorder (OSFED), the latter of which afflicts as many as 60 percent of the patients in treatment for eating disorders—presents an uncomfortable paradox. On the one hand, Americans are surprisingly educated about anorexia. Eighty-two percent of people surveyed in 2010 described eating disorders as a serious mental and physical illness, with only 12 percent dismissing them as afflictions of vanity.

On the other, cultural portrayals of anorexia have become inextricable from the disease itself. At LitHub, JoAnna Novak has written about immersing herself in books about eating disorders as a teenager with anorexia. TV movies have bolstered the conception that such illnesses only affect young, white teenagers, but they also often provide a model for anorexics to follow. One discussion topic on the website MyProAna.com features an extremely thorough list of movies and TV shows about eating disorders; there are 11 pages of responses from users debating their various qualities: truthfulness, relatability, specific calorie and weight references. “Seen every single film and every single documentary about 20 times over,” one commenter wrote.

It might not be possible for filmmakers and documentarians to portray anorexia in a way that avoids triggering vulnerable viewers, according to Dr. Melissa Nishawala, the clinical director of the Eating Disorders Service at NYU Langone’s Child Study Center: “Because individuals struggling with anorexia nervosa often have an extreme drive to the superlative—to be the best student, to feel the most valued, and to become the thinnest—any film depicting anorexia nervosa risks igniting the quest towards starvation.” That said, Nishawala specifically advises against filmmakers including images of bony figures, focusing on numbers (calories or weights), or depicting scenes of specific eating-disordered behaviors.

When the trailer for To the Bone was released, it prompted a flood of critiques noting that the film appeared to contain many images and scenes that could be triggering to recovering anorexics. The problem, though, isn’t just with this specific film. It’s a whole genre, a culture, that has a morbid and complex fascination with emaciated female bodies. To the Bone, inspired by its director Marti Noxon’s own experiences with anorexia, is a largely sensitive and thoughtful treatment of the disorder, but it can’t dodge the fact that any truthful depiction of anorexia will, by its nature, trigger those who struggle with the disease. The question is whether the usefulness of recovery narratives is worth the damage done in feeding a cultural curiosity that’s deeply unhealthy.

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One of the best cultural dissections of anorexia in recent years is Katy Waldman’s “There Once Was a Girl,” a 2015 essay for Slate that incorporated Waldman’s personal experiences with eating disorders with a critical analysis of the literary narratives surrounding them. From the “fragile sylphs” of Victorian fiction to the “brilliant madwomen bent on self-destruction,” Waldman recounts how anorexia has long been fetishized in culture. Perhaps that’s because, unlike many other mental-health disorders, it’s predicated on self-control. Fasting, which has deep roots in various spiritual practices, is a way of denying physical gratification to prove the depths of one’s discipline and devotion.

Religious fasting was also one of the earliest expressions of anorexia. Rudolph Bell, the author of Holy Anorexia, has suggested that as many as “half of the 42 Italian women who lived and died in the 13th century and came to be recognized as saints exhibited an anorexic behavior pattern.” Emma Donoghue’s 2016 novel The Wonder deals with the phenomenon of young girls in the 19th century who claimed to exist without food, “fed” by the holy spirit alone.

The author Hilary Mantel, in a 2004 essay for The Guardian, considered how the virtue associated with fasting fits into a broader cultural sympathy for anorexia, compared with the widespread condemnation of binge eaters. “Though the temporarily thin find it easy to preach against the fat, we are much more interested in anorexia than in obesity,” she writes. “We all understand self-indulgence, but are afraid that self-denial might be beyond us.” Films like To the Bone, however well-intentioned, feed this fascination. Ellen does so many sit-ups per day that she has bruises on her spine. In one scene, she resists a bite of her favorite candy bar with extraordinary, painful self-resolve.

It isn’t just anorexics and spiritual leaders who preach the virtues of self-control. The most popular mantras propagated by trainers and fitness bloggers on Instagram (“sweat is fat crying”) are often indistinguishable from the slogans on pro-ana websites. We understand, as cultural consumers, that anorexia is a disease, but we also, in some ways, admire it, and all the abstemiousness that it implies. The on-hiatus NBC show The Biggest Loser, in which obese contestants competed to see who can shed the most excess weight, used to push the scripture of discipline and physical will to several million viewers a week. The author Roxane Gay once described “the spectacle of the contestants pushing themselves in inhuman ways—crying and sweating and vomiting—visibly purging their bodies of weakness.”

Despite anorexia’s disproportionate influence in the media, it receives pitifully little when it comes to researching who struggles with it, and why. Schizophrenia, which affects one-tenth as many people in the U.S. as eating disorders, got 10 times the funds in the 2011 National Institutes of Health budget, despite the fact that the latter have the highest mortality rate among mental illnesses. This is why, in part, so little is known about the demography of anorexics, and why movies have such power in influencing public perceptions about who suffers from eating disorders. To the Bone is notable in that the patients at Ellen’s treatment center include a young black woman and a male ballet dancer. But Ellen herself fits the popular narrative model as a pretty, white woman whose parents are wealthy and divorced. (The film gives no consideration to patients whose health insurance might not cover professional help, although in 2014, treatment for eating disorders was excluded from the list of “essential health benefits” the Affordable Care Act required insurers to cover.)

It’s notable, too, that the cinematic standard for anorexics isn’t so different from the standard female movie star: young, white, very attractive, very slender. In the 1920s, the National Eating Disorders Association states, the average body-mass index of Miss America winners was 22. By the 2000s, it was 16.9—just below the medical threshold for anorexia. Which leads to the question of whether there’s a positive way to address eating disorders onscreen. Accurate depictions of anorexia encourage better awareness of the disorder, but they also encourage those afflicted by it. Collins’s emaciated frame in To the Bone is viscerally shocking to most viewers, but will inevitably be offered up as “thinspiration” on pro-ana sites. Still, ignoring the subject altogether isn’t an option, since narratives that communicate how often eating disorders end in recovery are crucial.

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To the Bone is at least a step forward in how seriously it takes its subject. Noxon resists the splashy, voyeuristic model of Lifetime movies and tries to illuminate the confining reality of Ellen’s existence. It’s never intimated that her anorexia was the result of wanting to be thin or pretty; the movie has a fairly sophisticated grasp of how much more complex it is. Collins’s performance is deliberately small and restricted—only once does she raise her voice, and when she does, it’s jarring. Her doctors treat eating disorders like other addictions, addressing the highs they induce, and the lows they help paper over. “Starving yourself can make you feel euphoric, like a drug addict or an alcoholic,” a counselor at Ellen’s inpatient facility says.* “What you crave is the numbing of the thing that you don’t want to feel.”

Oddly, though, one of the most insightful treatments of anorexia in film embraces the exact same kitsch that characterizes many of those Lifetime movies. In 1987, the filmmaker Todd Haynes made Superstar: The Karen Carpenter Story, a retelling of Carpenter’s life. The 43-minute movie is famously difficult to see, since it was banned after Haynes neglected to get permission for any of the songs he featured. Here, the paradox of portraying anorexia is key: Haynes incorporates and subverts virtually every cultural trope when it comes to eating disorders. The “characters” are played by Barbie dolls, archetypal representatives of unrealistic female body types. Haynes reportedly whittled away at the doll he used to “play” Carpenter to show her disorder getting worse, in a disturbing visual manifestation of anorexia’s effects that didn’t require an actress to lose unhealthy amounts of weight.

The movie, too, is saturated with modern American culture, and its style emulates the breathy, insincere format of 1980s television. In one frame, Haynes focuses on the branding of a packet of  the laxative Ex-Lax, as iconic as a Campbell’s soup can. In another, nightmarish scene, he conveys Carpenter’s disintegrating mental state by filming from her perspective while all her biggest hits play on top of each other in an aural simulation of obsession and overconsumption. But he also illuminates some of the factors that often contribute to anorexia: a controlling familial environment, anxiety, and obsessive, insular thinking.

Superstar is an impossible work to emulate, but it proves that filmmakers can expand the scope and potential of works about eating disorders without contributing to the culture that encourages them. They just have to get more creative. Nishawala recommends that filmmakers only show characters layered in clothing to avoid images of skeletal frames, and that they focus on the relationships characters have, and other aspects of their lives, rather than just their disordered behaviors. She also emphasizes that it’s important to portray treatment as effective. “Perhaps part of the story would be told through sessions with a smart, effective therapist who helps by building skills and helping the individual with the eating disorder to become stronger and more insightful,” she says. “Maybe that’s a dream, but I would love to see it.”

Just as important is redefining the common perception that people of color don’t suffer from eating disorders, or that they only afflict young women. Some of these works will inevitably be triggering. Angela Gulner’s webseries, Binge, includes graphic, uncomfortable dramatizations of Gulner’s experiences with bulimia, which Gulner has said is her intent—she wanted others who’ve experienced it to know they’re not alone. Others might be necessarily horrifying, like Rodrigo Prieto’s 2013 short film Likeness, which stars Elle Fanning as a teenager with crippling body dysmorphia. But the more they chip away at perverse, reinforced portrayals of eating disorders, the more potential they have both as works of art and forces of change.


* This article originally misattributed this quote to Keanu Reeves's character. We regret the error.