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As eating disorders among teens soar in pandemic, YA novel takes on grave issue

For debut work of fiction about anorexic high school girls, 25-year-old E.J. Schwartz draws on her own recent experience of social media-influenced devastating drive for thinness

Renee Ghert-Zand is a reporter and feature writer for The Times of Israel.

Illustrative image: Dena Rubanowitz describes her struggle with an eating disorder with a caption that reads 'I am not my eating disorder.' (courtesy What I Be)
Illustrative image: Dena Rubanowitz describes her struggle with an eating disorder with a caption that reads 'I am not my eating disorder.' (courtesy What I Be)

When author E.J. Schwartz began writing her young adult novel about eating disorders just before the Covid pandemic hit, she had no idea just how timely its publication would be. The number of new cases of children and teens with eating disorders has skyrocketed since the onset of the pandemic in early 2020.

The novel, “Before We Were Blue,” is set in Recovery and Relief (RR), a fictional American residential treatment facility where protagonist Shoshana Winnick experiences  treatment for anorexia for the first time. The other main character, lifelong anorexic Rowan Parish, is a veteran of residential therapeutic settings.

The two teenagers meet as “gray girls” at RR, meaning they are at high risk and require constant supervision, especially while eating. These residents are evaluated weekly to see if they have progressed enough to move downstairs and become “blue girls,” who are allowed self-monitoring at mealtime, and physical activities such as dance.

The novel begins with Shoshana, Rowan and others discussing a discharged patient who they heard has died by suicide.

“Remember how she faked her period so they lowered her goal weight, and she gained the last five pounds by stuffing quarters in her underwear, then got out on early release?” says one of the girls quite matter-of-factly.

Author Schwartz, 25, drew from her own experience with an eating disorder in writing “Before We Were Blue.” This includes her familiarity with “pro-ana” and “pro-mia” online communities, as well as social media “thinspiration” content.

‘Before We Were Blue’ YA novel by E.J. Schwartz (North Star Editions)

“I pulled from my own experience, my friends’ experiences, and I did research for my novel. I was never in a residential treatment program, but I interviewed professionals who work at some of these places,” Schwartz said.

The serious uptick in anorexia, bulimia and other eating disorders among young people during the pandemic means that in real life, inpatient eating disorders programs, as well as outpatient ones, currently have long waiting lists.

The lack of available treatment was brought to the fore in Israel when the Knesset devoted a full day on February 15 to the subject and what is being done to help the estimated up to 100,000 Israelis (the vast majority ages 15-24) who suffer from them.

A report prepared by the Knesset Research and Information Center revealed that the recent increase in eating disorders cases has greatly outstripped the country’s existing treatment options — both in the public and private sectors. With eating disorder cases jumping by an estimated 56% between 2019 and 2021, there are simply not enough clinics, hospital beds, and qualified staff.

“The situation is very serious right now,” said Dr. Adi Enoch-Levy, director of eating disorder services for children and adolescents, and head of the in-patient unit for eating disorders, at Sheba Medical Center at Tel Hashomer.

Dr. Adi Enoch-Levy, director of eating disorder services for children and adolescents at Chaim Sheba Medical Center, Tel Hashomer (Courtesy)

Haaretz recently reported that at Sheba’s program, the largest in the country, there are hundreds of teenagers (mainly girls) on the waiting list to get in. It can take up to a year right now for a spot to open up. Thousands more girls are waiting for available spots at other locations.

The same problems are seen outside Israel. It’s been a struggle for Devorah Levinson, director of the eating disorders division of Relief Resources, a US-based international mental health referral organization for Orthodox Jews, to keep up with the demand for help.

“In 2021, we had 345 new cases, with two-thirds of them ages 13-25. Pre-Covid, we had 230 new cases annually on average. Access to help slowed down, especially at the beginning of the pandemic,” Levinson said.

Sheba’s Dr. Enoch-Levy emphasized how important it is to identify and address eating disorders early. There is no time to lose, as patients are unable to cooperate with psychotherapy, and medication won’t help them, until they have regained a certain amount of weight. But with the backlog caused by the pandemic, it is difficult for most parents to get the treatment ball rolling for their children.

When every man is an island

A distorted body image is at the core of most eating disorders, according to Enoch-Levy. The isolation imposed on teens by the pandemic has amplified this distortion for many.

“Covid has served as a trigger for kids vulnerable to eating disorders and other psychiatric illnesses,” said Prof. Yoav Kohn, director of the Donald Cohen Child and Adolescent Psychiatry Department at the Jerusalem Mental Health Center and the Eitanim Psychiatric Hospital.

Being forced to stay at home for so long, away from friends and regular routines, has made teens feel a loss of control over their lives. Some have turned to severely restricting their food intake or extreme exercise as a way to regain control. In some cases, parents’ well-intentioned warnings to kids against overeating while cooped up at home have had unintended negative consequences.

Prof. Yoav Kohn (Courtesy)

However, well before the onset of Covid, social media played a dangerous role in triggering vulnerable young people, whether because they have co-morbid mental health conditions such as anxiety, depression, suicidality, OCD, or PTSD, or because of a genetic predisposition. (Kohn cited studies showing that while the risk for anorexia within the general public is 1%, it is 10% for a person with a sibling or other first-degree relative with anorexia, and 50% for identical twins.)

Enoch-Levy noted that anorexia and bulimia communities can overlap. “There is a lot of transition between eating disorders. For instance, 60% of anorexics also become bulimic,” she said.

Psychiatrists Enoch-Levy and Kohn both claim that social media platforms like Instagram and TikTok have become more central to teenagers’ lives over the last two years, and that they are seeing the detrimental effects of this.

An October 2021 New York Times article quoted Chelsea Kronengold, a spokeswoman for the National Eating Disorders Association as saying, “Social media in general does not cause an eating disorder. However, it can contribute to an eating disorder.” The article goes on to say that “the association advises social media companies to remove content that explicitly promotes eating disorders.”

Deborah Levinson, director of eating disorders division at Relief Resouces (Courtesy)

Levinson from Relief Resources emphasized that appearance ideals and the drive to be thin even are prevalent in Orthodox Jewish communities, which purport to isolate themselves from outside influences.

“The Orthodox world has several intentional buffers against the influence of secular culture, but with the advent of the internet it has become more difficult to limit this exposure. Kids may not be on social media as much as in the secular world, but many Orthodox people shop online, where they get negative messages from seeing the thin models wearing the garments,” Levinson said.

“As a result, Orthodox clothing manufacturers are pressured by customers to make clothes in smaller sizes and slimmer designs. Orthodox magazines have featured columns about families and girls on diets, and run ads urging young women to slim down for shiduchim [dating for marriage],” she said.

Art imitating life

“Before We Were Blue,” Schwartz’s first book, is classified as YA literature for 13 year olds and up. However, it is most appropriate for high school upperclassmen and older, she says.

Written from the alternating perspectives of the Jewish Shoshana and the non-Jewish Rowan, it deals not only with difficult psychiatric and eating disorders-related content, but also with the codependency between the two protagonists.

‘Before We Were Blue’ author E.J. Schwartz (Lee Lapalucci)

“There is an intensity, a longing in female relationships, that is natural to girlhood, and actually never leaves us. It’s a best-friends-against-the-world thing,” Schwartz said.

Although Schwartz said she purposely put distance between herself and her characters, there is much of the author in Shoshana. Like her fictional protagonist, Schwartz grew up in New Jersey in a strongly-identified Jewish family, and thought a lot about what she believed religiously, and why.

Schwartz also drew inspiration from her own years as a competitive gymnast and cheer athlete to create Shoshana. In the novel, Shoshana ends up at the residential program after starving herself to stop her growth spurt so as to be able to maintain her outstanding tumbling skills — and  her thin appearance in the required skimpy cheer uniform.

Shoshana has to contend with the cruel methodologies and low-level antisemitism of her coaches, as well as TV cameras constantly trained on her as part of filming for a reality show akin to Netflix’s hit “Cheer.”

Shoshana’s personality profile fits well with many young people who succumb to eating disorders, according to psychiatrist Kohn.

“Persistent, competitive people can get eating disorders more easily, because they have the willpower to over-exercise and under-eat,” he explained.

E.J. Schwartz (center) at age 16, at ‘Battle at the Capital’ cheer competition in Washington, DC in 2013. (courtesy)

Levinson said she has seen an OCD-scrupulosity factor evolving from religiosity among anorexic teenage boys and young men in the Orthodox world. With Orthodox boys leaving home as young teenagers to attend boarding school yeshivas, parents are not around to perceive extreme changes in weight.

“We need rabbis familiar with mental health and eating disorder issues. We try to educate the rabbinical community,” Levinson said.

In her experience, rabbis who are knowledgeable prioritize the best clinical care for those who are suffering. For instance, they will allow a patient to eat non-kosher food if a treatment center cannot provide kosher food.

According to Schwartz, the intended takeaway from “Before We Were Blue” it is that it is time for girls and young women to break free from what society has told them to be — smaller, daintier, prettier, quieter and more polite.

“These are learned behaviors, and it is time for girls to unlearn them,” Schwartz said.

“This novel is pretty dark, and readers won’t come away from it with any solutions, but I think it’s a story that young people should be reading right now,” she said.

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