MIGUEL BOYAYANPediatrician Mauro Fisberg watched a fashion show for the first time in ten years. It was not to see the novelties, but to accompany the adolescents who were working as models and were beginning to be attended to in the ambulatory clinic that had just been created at the Federal University of São Paulo (Unifesp). In view of the death of healthcare for adolescents who dream of being a Gisele Bündchen, Fisberg began a few years ago to discuss with the model agencies what to do. Before, he was little heeded. Now, after the death of the Brazilian model Ana Carolina Reston and of the fashion student Carla Casalle, he has observed a greater willingness for dialog and a joint quest for solutions. Models, though, are not the only victims of pressure for a perfect body, which also pursues gymnasts, ballerinas and actors. Fisberg knows that he will not manage to prevent 12 or 13 year old girls and boys from going into these professions of high risk for health, but he advocates a more intensive supervision for the youngest, with a minimum age for starting work and a continuation of their studies.
How do you evaluate the attention that was given to the death of the two Brazilian models from anorexia?
It is transitory. I do not believe that there’s going to be a discussion of a change in corporeal image of the models. It’s the market that defines the standard. Not the domestic market, but the international one, which has a turnover of billions and billions of dollars and is not guided by health. Today, the dress size most sought after is 38; ten years ago it was 40 or 42. Some years hence, it may be 43, 44, 45, it does not matter. This present-day concern with health is, unfortunately, momentary. A bit later on, it will be forgotten by the media. More than for seriousness, the two deaths won visibility for the media being a former of opinion and because fashion is nowadays associated with thinness, an eye-catching and complex situation. Unfortunately, there is a standard of esthetic consumption. Just as boys want to be soccer players, a glamorous profession that in theory brings high rewards, girls want to be Gisele Bündchen. It is an absolutely distorted vision. Only one boy or girl amongst millions of the same age succeeds in becoming a model or a soccer player. The problem is that these professions represent a tremendous opportunity for social ascension that, at least in principle, does not depend on physical labor, but on the person’s physical characteristics. There is a group of girls that has the biotype suitable for being a model, but our fear is that normal girls may seek characteristics that they cannot attain, because they do not have the type of body that they need to be a model. They are going to do the utmost to get a body close to this, and therein lie the great risks to health. We have seen that mothers and fathers are great abettors and accept any sacrifice in the name of this possibility of social ascension.
In September, the organizers of the Madrid Fashion Week said that models with a Body Mass Index (BMI) of lower than 18 would not go onto the catwalk. How does that seem to you?
It was a proposal for a single week, it isn’t a national law. It was adopted by Russia and by Israel, but France, the United States and the whole of the East rejected it. Paris has another, more interesting kind of restriction: girls less than 16 years old are not accepted. We have to think about these proposals, because there has still not been any scientific discussion. Where did the body mass index of 18 come from? It’s an arbitrary index, from people who don’t work with adolescence. Theoretically, the BMI for a woman to be considered healthy is 18.4. Furthermore, BMI is a measure of population distribution. The probability of a girl with a BMI of less than 18.5 being undernourished is 95%. But 5% of them are not undernourished. Another point is that it is a purely anthropometric characteristic, in itself, it’s no use for anything. We have to evaluate other characteristics to assess other characteristics to see if a person is healthy, such as age and sex. A part of the girls with a low BMI are within the range of normality. They are thin and healthy, whether they are models or not. The older Brazilian models, of an international level, have an average BMI of 17 or 17.5. It varies a lot in the younger models. A 13-year old girl with a BMI of 15.6 may be healthy, even if she’s not a model. If we arbitrarily determine BMI 18, there will be a large universe of girls, from 16 to 18 years old, with a BMI of less than 18 who are absolutely normal from the clinical, pediatric or medical point of view.
Isn’t it a good thing that someone has cast an initial value and opened up the debate?
We ought to do the same with other professions. There are two activities that merit more attention: gymnastics and ballet. Their performers are subject to an intense pressure, they live under strict rules, and they resort to subterfuges to reduce weight and to lose body mass. For years we have been accompanying risk groups from rhythmic gymnastics, but as the number of gymnasts is small, the problems do not call attention. It was only recently, after they began to win medals, that they started to be better known.
What is the risk of people from these two groups, ballet and rhythmic gymnastics, developing eating problems?
It is more than with models. Eating disorders include a series of psychiatric pathologies: anorexia, bulimia, compulsion, and two other pathologies that have not yet been determined but that are now being much discussed: orthorexia and “vigorexia”. ( bigorexia or muscle dysphormia)
What are they?
Orthorexia is the pathological quest for the perfect body or healthy lifestyle. They are people who only do something if it is determinant for health. It could even be interesting, were it not taken to the extreme. And, with vigorexia, the person is incapable of remaining seated for one minute because he thinks that he is not burning calories. But you have to take care not to mix up eating disorders with altered eating behaviors. To determine the diagnosis, a psychiatric evaluation is necessary. Following a diet is one of the criteria that are used to determine the diagnosis. But following a diet can be normal or pathological, in the same way that vomiting after eating too much can be a pathological characteristic or represent a stage of risk. For it to be classified as bulimia, the behavior has to be repetitive and there have to be other symptoms, such as the excessive ingestion of food and guilt associated with the attempt to eliminate it.
What is the prevalence of eating disorders in the risk groups?
In the worldwide population, the prevalence of eating disorders is from 1% to 2%, and bulimia is three times more common than anorexia. In the risk groups – in which there is pressure for corporeal modification, such as athletes, models, ballerinas, gymnasts, jockeys, actresses and students -, the probability of developing eating disorders is from three to five times greater. Anorexia is an adolescent’s disease, but not all adolescents show a risk of developing anorexia. The risk of showing inadequate behavior is greater amongst the models, but that does not mean that they will have more diseases than the other adolescents. Among the girls attended to here in the ambulatory clinic, the prevalence of eating disorders is no greater than in the population. They show more risk behaviors, but it doesn’t mean to say that they have more diseases. People mix things up: they say that every thin model is anorexic. It’s a lie. At the Ford Agency entry exam, held soon after the death of Ana Carolina, the media turned up en masse. I have never seen so many reporters accompanying the models, surprised because they would eat more than they did. It’s logical, they are adolescents, they eat like mad, but they are thin. They can eat junk and put on zero weight. The problem is that their bodies are in transformation. That is why we believe that, to begin to work as a model, the girl must at least be pubescent.
Because then their bodies have now changed and the measurements are more stable. It’s different from a 12 or 13 year old girl, who is going into the career and has the perfect body for the biotype that she needs at that moment. But a year hence, her body changes: it keeps on growing, taking on new contours. The agencies tell her to come back with 88 or 90 centimeter hips, but she has 92. This girl has no fat to lose. It’s an arbitrary characteristic that we are discussing with the designers and agencies. It is common for them to send models away, to come back only after they have lost 10 kilos. Some girls can lose 10 kilos and be perfect, but others, not. Will they manage to lose weight in a healthy way? Or are they only going to lose weight if they do plastic surgery on the bones?
MIGUEL BOYAYANHow is this dialog with the agencies going?
There’s a lot of discussion. We made a challenge to the agencies and to the designers: for the people from the healthcare area and those from the fashion area, working together, to define a suitable standard for corporeal modifications. The death of Ana Carolina opened up a dialog with the fashion industry. A short time before, we convened a meeting and only representatives of four agencies appeared, no director. Now I am already managing to talk to the directors.
What is the role of each one to prevent health problems with the models?
Everybody has responsibility. The media have a gigantic culpability because they exaggerate in several things in search of the model, the news. The family has a great responsibility. I would never let a 12 or 13-year old daughter leave the interior of Brazil to live alone in a big city and afterwards go abroad without accompaniment. Because this child or adolescent is going to enter a competitive world with constant rejection. The models get noes every day, even when they are perfect, because the customers want characteristics that they do not have. And they have to have a great structure for that. Now, when you are 12, 13, 14 years old, you think you are a great person, you were chosen as a model and are rejected. Remember that they are in transition, undergoing corporeal changes, and with an extremely low self-esteem.
Are they getting psychological help?
Some agencies offer psychological help. But there are agencies and agencies. Some are absolutely professional, others talk a lot and do nothing.
And how did the idea arise of creating an ambulatory clinic for adolescents who wanted to be models?
There were two situations of great interest and high risk: being an adolescent and being a model. I had already attended to some candidate models at an ambulatory clinic, sporadically, and I saw that they were very unprotected. They didn’t have health insurances, nor did they do health examinations. The first agency we worked with was Elite. We did the first evaluation of the finalists of a national entrance exam. There were 100, 200 girls, coming from all over Brazil. We didn’t imagine that they were so thin, so tall, and came from so many regions.
Have you ever been to a fashion show?
Yes, but accompanying the models as a health professional. They sometimes faint, from the tension or from the time they remain under the heat of the spotlights. The emotional pressure is very strong, and they can have a fit at any moment, because of the tiredness, tension and emotional alterations. From then on, we began to work with other agencies that turned to us. It has always been a service free of charge, our objective has always been scientific.
What kind of service do you provide the agencies with?
We have three types of follow-ups on the models’ health. The first is the accompaniment of the entry exams of some agencies. We also have a second way of accompanying: we receive here the new faces, which are the new girls, who are starting the career, for consultation and accompaniment. We normally attend to them until the age of 20. But we continue to treat some of those who have already been with us, if necessary. We do the examinations and the clinical accompaniment of all the medical specialties. The third program for accompaniment is the home visit. We visit the models’ apartments. The great majority of these girls live in apartments that may have from 5 to 15 models. It’s a big risk, because they have to cook and take care of themselves on their own. They are not going to make sophisticated dishes, but the simplest possible, some instant noodles, it is only if they have money that they are going grill some meat. The problem is that they have inadequate concepts about eating, and they think that they cannot eat rice and beans, that they mustn’t eat bread, that they can only eat until 8 o’clock at night. Like all adolescent who is on her own, they have no one to ask. That’s what we are trying to change.
What problems appear most?
Menstrual problems, as in every adolescent girl, intestinal constipation and dermatological problems. They are also very concerned with following diets, generally inadequate ones. We offer general orientation on eating, sport and recreation. And emotional orientation, which is our great concern, so as not to let them get too fat or too thin in an inadequate way.
Can you count on the support of the adolescents’ families?
When necessary, we call the family. They have the power of veto, and we can send the girl to her city of origin if she does not match up to a given health standard.
Do they agencies take your opinion into consideration?
They should. In the last few years, and particularly now, with the death of Ana Carolina, there has been a greater understanding. But there are agencies that, despite having an agreement with us, have never sent any girls and have no interest in what we do.
How many model agencies do you serve?
We work with all the big agencies in São Paulo and some small ones as well. There are about 12.
Which problems are being forgotten?
One of them is premature work. Modeling, like being an artist, is a profession of exceptions, which brings together people who in theory could not work and are working. Children and adolescents are working as actresses and as models, subjecting themselves to the world of egos, rejections and family interests. They are going to carry on working as models or artists, but we believe that there must be intensive medical accompaniment. The second point that we advocate is for there to be a discussion about the minimum age for work. For example, even if an age is discussed, it can be 15, 16, the girls below this age are not going to stop being models. Obviously they are going to continue, but let them be considered as apprentices, as in other professions, and undergo a greater supervision that the older ones. In these cases, we can ask for the families to be together with them: of course, these measures still have to be discussed with the whole of society. The third thing that we are proposing, which is the great challenge for the agencies, is obligatory studies until at least the end of the basic cycle. They stop studying when they go abroad. Many models study, but irregularly. Unfortunately, many schools allow them to be enrolled, but do not insist on attendance and give a schooling certificate.