Anorexia Turbocharged: On Hadley Freeman’s “Good Girls”

THE JOURNALIST Hadley Freeman begins her memoir Good Girls: A Story and Study of Anorexia (2023) with a diary entry from December 3, 1995, when she was 17: “I just spent three years of my life in mental hospitals. So why am I crazier than I was before????” Freeman was suffering from anorexia nervosa, and she would continue to restrict her food intake in a way that significantly affected her life until her mid-thirties. Now 44, she looks back at her experiences to consider what they might mean. Given the complexity of the illness, it’s a formidable task.

What Freeman calls “the trigger” came during a PE lesson at school. Casually comparing her limbs with those of the thinnest girl in the class, she asked the girl whether she found it difficult to buy clothes:

“Yeah,” she said. “I wish I was normal like you.”

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

Many sufferers recall a moment like this. For some, the illness then “creeps up slowly as a cat,” but for Freeman it was “instantaneous and vertiginous.” Viewing her body in a new light, and with contempt, she cut out entire food groups, then meals. Formerly totally uninterested in exercise, she embarked on a punishing regime. Her thinking, meanwhile, became ever more distorted: “Am I taking in calories when I chew on my lips?” she wondered. “Or walking past a supermarket?”

Newly sensitive to messages telling her that she should be thin, she now found them everywhere: “Being a woman seemed like an unceasing battle against one’s body, and I thought I was gaming the system by starting early.” But Freeman is careful to say that her illness was more than a diet gone wrong—that “the cause is very different from the trigger.” One chapter provides an “incomplete list of reasons doctors, therapists and outsiders have given over the years for why I became anorexic.” “I was born by caesarean,” it begins; “I was the firstborn.” “My parents were too strict,” she recalls, or “[m]y parents were too indulgent.” A faint air of desperation builds as the theories pile up, 75 of them: “I was exposed to toxins as a baby”; “I had inherited trauma from the Holocaust”; “I was part of the zeitgeist”; “I was bored.”

Unsatisfied, Freeman searches her childhood for clues. She remembers longing to fit in and please everyone, but also to be special in some way, to have a distinct identity. A “mad, bad and sad feeling” would often surface; at times, her anxiety expressed itself in obsessive-compulsive tics. A large part of Freeman’s unease, she reflects now, stemmed from her fear of the demands of adulthood, and of femininity in particular. “Femininity is passivity,” she writes. “[Y]ou are observed, you are judged, you are chosen. And the closer a girl gets to womanhood, the more femininity can feel like her doom.”

Interwoven with Freeman’s story are interviews with clinicians and researchers. Dasha Nicholls, a clinical reader at Imperial College London, says that the biggest risk factors for the development of eating disorders are “being female, body image dissatisfaction and dieting behavior.” Anorexia usually arises during adolescence; along with the hormonal changes of puberty often come physical and social discomfort. The illness is thought to be about 60 percent heritable. The psychiatric geneticist Gerome Breen says that people who develop it tend to have a high metabolic rate and low blood sugar, and that food restriction may therefore have a greater effect in them than it would in other people. Some studies suggest that people vulnerable to anorexia have high levels of serotonin in their brains; this may mean that they experience heightened anxiety that is relieved by starvation. Other studies have found a surplus of dopamine, which may explain why anorexic people can abstain from everyday pleasures for long periods.

Agnes Ayton, chair of the eating disorders faculty at the Royal College of Psychiatrists, says that 30 to 35 percent of patients with chronic anorexia who don’t respond to treatment also have autism spectrum disorder. (The link with autism is complicated; Freeman learns that “symptoms of starvation can be mistaken for symptoms of autism.”) Certain personality traits have long been associated with anorexia, and it is these that Freeman finds most compelling: an article in The American Journal of Psychiatry cites “introversion, conformity, perfectionism, rigidity, and obsessive-compulsive features.” Freeman describes her younger self as oversensitive and lacking in perspective, and she asserts of her hospital cohort that “in the vast, vast main, nothing massively terrible had happened to any of us. It was just an accretion of small, normal-awful life experiences that we had metabolized differently from most people.”

Freeman offers a vivid account of the “splitting” that occurred as her anorexia took hold: “That warm evening when I walked with my parents to our local Italian restaurant, and I asked my mother whether pasta was fattening: Shatter! That lazy August day when I went out to buy a book for school and instead bought a calorie counter: Smash!” She lost a third of her body weight in a few months and “straddled […] two countries, still able to speak the language of the former but adhering to the customs of the latter.” She asked herself what the “end game” was: “‘I just need to be thin enough so I can eat what I want without getting fat,’ I’d think. But I never asked myself what ‘thin enough’ would be because my brain was too busy reveling in erotic fantasies of the foods I would eat.”

Freeman describes being tired all the time, but exercising constantly. Much of the hair on her head fell out and she developed a “soft downy pelt”—lanugo—on her abdomen, arms, and back. Her world shrank “to the size of a pinhole.” She collected recipes and secretly smelled the food in her parents’ kitchen at night instead of eating it. “Women’s bodies suddenly fascinated me,” she writes. “Fascinated and repelled. I stared at the ones in tight clothing: the waistband digging, the sleeves gripping. How could they bear it?” One darkly funny chapter is titled “Anorexia Speak,” after the language in which all sufferers seem to be fluent. “I don’t know how you have the energy to do so much exercise,” somebody might say, but Freeman would hear, “You are extremely impressive, and also I am watching everything you do, so you’d better keep doing it or I will comment on your laziness.” “Don’t you want to be healthy again?” would become “Don’t you want to be fat again?”

Starvation causes cerebral atrophy, altering “your brain chemistry so that you become more depressed, more emotional, and more confused in your thoughts. The knock-on effect aggravates the cause.” Eventually, Freeman was so worn out by her disorder that she agreed to see a psychiatrist. Now came the first of nine admissions to the hospital. Faced with the requirement to eat properly, she became “a whirling ball of anguish, fear and desperation.” When she was prescribed lithium and Prozac, she had a seizure. This scared her into accepting that she had to put on weight, but she had a plan: to gain the weight as rapidly as possible so that she could be discharged and then lose it again at home. The hospital can be life-saving, she reflects, but it can also harbor superbugs—in her case, “Anorexia Turbocharged.” “Whereas before, my approach had been clumsily instinctive and blindly ignorant, I had emerged from hospital knowing exactly what I was doing and determined to keep on doing it.” Anorexia has the highest mortality rate of any psychiatric illness, and at one stage Freeman’s mother was told to prepare for the worst.

Not even specialists, we learn, can predict who will recover and who won’t. Ayton says that about a third recover; the rest either remain ill or improve but have difficulties. Freeman was fortunate to find a therapist who “knew how the black snake in my mind worked and could always tell when I was lying or hoping to get away with something.” She stopped exercising, and was surprised to find that her body barely changed. A breakthrough came when she looked at a fellow patient and thought: “I will not be having temper tantrums over toast when I’m thirty-two years old.” Success in her General Certificate of Secondary Education exams made her think about the future she could have if she left her illness behind. Years later, when trying to save herself from a relapse, she was told by a nutritionist that she could lose a few pounds if she wanted to, and she laughed and cried in despair. She realized, at last, that “I would have to stop trying to outsource my recovery […] Only I could do it.”

Freeman writes, perceptively, that “anorexia is not about the food, it really isn’t. But it becomes about the food, and the only way out of it is through the food”: you have to eat consistently, every day, even though your brain is screaming at you not to. Those who are able to persist tend to find (as I did) that the fear and guilt start to subside, and it gets easier. You relax, you let go of anxious compulsions, and your natural inclinations, long overridden, gradually return. In this book, it might have been worth emphasizing even more powerfully that full recovery from anorexia is possible, and that with it comes mental freedom.

Sufferers often understand one another. “When I talk to the women with anorexia,” writes Freeman, “their emotions and thought processes rarely vary that much from what mine were, just as one person’s bout of chicken pox will have much in common with someone else’s.” Some chapters of Good Girls are devoted to interviews with people Freeman met in treatment; one chapter is not an interview but a loving portrait: Fritha Goodey, who stood out for her kindness and went on to become an admired actor, continued to struggle and took her own life in 2004. Freeman writes, with sympathy, that “there are surely few worse professions” for someone with anorexia.

Fashion journalism—the world Freeman entered after university—might seem hazardous too, but she had “fully explored the promise that thinness leads to happiness and seen what a mirage that was.” Fashion’s “obsession with skinniness reflects how deeply the association between female self-denial and perfect femininity is entrenched in our culture,” she writes. “This doesn’t cause anorexia, but it gives it a softly fertile ground in which to breed.”

“The mediums change,” writes Freeman, “but not the emotions, and anorexia is deeper and has a longer history than either Vogue or Instagram.” She traces that history back to the legend of Wilgefortis of Portugal, the “original anorexic,” who stopped eating when her father selected a man for her to marry: “By the fourteenth century, she was worshipped as a saint who had ‘divested herself of female problems.’” Today, Freeman sees an “epidemic of extreme anxiety among girls.” She mentions a study published by The Lancet Psychiatry in 2019 that showed that the prevalence of self-harm among girls and women aged 16–24 in England had risen from 6.5 percent in 2000 to 19.7 percent in 2014 (the prevalence among boys and men had risen from 4.2 percent to 7.9 percent). In 2022, another study, which examined 15,000 secondary school pupils, found that “girls are twice as likely to suffer mental health problems as boys by the age of eighteen.” Freeman also discusses the possibility of a link between levels of adolescent female unhappiness and a large increase in recent years in the proportion of female patients referred to the NHS’s Gender Identity Development Service (GIDS). In one passage she writes:

In the winter of 2021 I spoke to Anastassis Spiliadis, a psychotherapist who has worked in GIDS and eating disorders clinics, and he told me: “We are heading to a similar sex ratio in GIDS as in eating disorders clinics, which are ninety to ninety-five percent female in the adolescent cohort. That makes me think about female adolescence, and how that can be traumatic for some girls, and whether we are doing a good enough job to support young people and to help them connect with their bodies in a healthy way.”

The treatment of anorexia has changed over the past three decades. When Freeman was in the hospital, patients lingered for hours over meals, drawing out the agony; now, there are time limits. Freeman was rewarded with privileges when her weight went up and punished with their withdrawal when it went down. (Weight therefore “became an entire economy that I traded in,” she writes: “How much can I get for this pound? What do I owe you, Doctor, for that visit with my parents?”) Today’s approach is less combative and more individualized. Sarah McGovern, a ward manager, says that “[i]t’s about finding a balance between us taking all the responsibility and them gradually taking it back.” When Freeman first became ill, her mother was told that her “entire focus” should be on her daughter and her recovery. Freeman’s second psychiatrist, Janet Treasure (still a leading authority in the field), was, by contrast, “emphatic” that family life should continue as normal, “and she was right.” It offered a vital connection to the outside world.

Freeman evokes the mental processes of anorexia extraordinarily well, and her candor will make a great many people feel less lonely. Because she focuses on her own experience in Good Girls, she mentions male anorexia only in passing. But that doesn’t invalidate what she offers at the end of the book—a summation, over two pages, of all the things she wishes we would impress on girls to spare them the sort of misery she went through: “I wish we would tell them that […] sometimes they will let people down, even their parents, and that’s okay,” she writes. “I wish we would tell girls that their bodies are not an outward show of who they are. […] I wish we would tell them that no teenager knows who they are yet and it’s normal to feel like nothing right now and one day that will change, but only if they are kind to themselves.” It’s impassioned, a sort of manifesto, and we should take it to heart.

¤

Catharine Morris is associate editor of The Times Literary Supplement.