Perspective Chapter: Social Networks and Eating Disorders - Beauty and the Beast?

Abstract

Currently, social networks are part of the lives of adolescents, who make intensive use of them to relate to each other and to the world, making them a major factor in socialization. This has led to a great deal of scientific research on the influence of this means of communication in many areas of the life and development of adolescents, especially in the field of both physical and mental health. This paper reviews some relevant psychological phenomena associated with the use of social networks to understand their influence on adolescent behaviour; the main psychosocial risk factors for problematic internet use at this stage and their possible relationship with eating disorders based on recent research findings; as well as some proposals adopted within the European Union and in Spanish legislation for the control of harmful content on the Internet, especially those related to the advocacy of anorexia and bulimia, which until very recently escaped any possibility of control despite their importance for public health. Finally, we briefly discuss the potential of technology to implement these controls and present a research project for the detection and neutralization of apology of ED on Twitter, funded and implemented by the APE Foundation with the collaboration of the University of Zaragoza.

1. Introduction

The use of social media has experienced a growth boom in recent years, a trend that continues unstoppably. In April 2022, it is estimated that there will be 4.65 billion social network users, which represents 58.7% of the world’s population [1]. The latest study on the impact of technology on adolescence conducted by UNICEF Spain in 2021, indicates that 98.5% of adolescents are registered on at least one social network [2]. The same study concludes that the use of screens is a non-negotiable contribution to adolescents, both socially and emotionally.

These data are important in view of the prevalence of eating disorders, whose target population in Spain is women aged 12–36 years, with a prevalence ranging from 4.1 to 6.4 % between 12 and 21 years; it is one of the three most frequent chronic diseases among adolescents, a population in which it appears at an increasingly younger age [3]. A recent review of the scientific literature found that adolescents are a risk group for the development of eating disorders and the media is a contributing factor to dysfunctional eating behaviour [4].

On the other hand, some psychological phenomena characteristic of the use of the internet and social networks such as the so-called echo chambers and filter bubbles have been the subject of research into their effects and the possible relationship between the use of social networks and eating disorders in adolescence; This, in turn, has led to a growing concern of government authorities to control harmful content related to anorexia and bulimia distributed on the internet [5] and has stimulated the development of legislative measures and technical-scientific lines of research aimed at this objective.

2. Echo chambers and filter bubbles

The term echo chamber refers to the cognitive isolation in a media space of the user of digital content, which has the power to enhance the messages emitted in that space [such as a website, a blog, or the wall of an Instagram profile] while shielding them from hypothetical refutation [6]. This phenomenon is based on the so-called confirmation and disconfirmation biases, whereby people unconsciously tend to preferentially seek out information consistent with their prior beliefs and expectations while ignoring data that contradicts them [7].

The filter bubble is essentially an echo chamber resulting from the application of content personalisation algorithms implemented by the platforms on which they are offered, based on the user’s previous activity, with the aim of providing them with content that is more attractive, interesting and in line with their interests [8].

The main difference between the two phenomena lies in the type of choice made by the user, more active in the case of echo chambers and totally passive in the filter bubble, since the content becomes accessible to the user after a prior automatic process of data analysis that is beyond their control, and which replaces the active choices themselves.

Recent research has focused on the possible link between these phenomena and eating disorders. The filter bubble is strongly associated with social networks, allowing users to choose which accounts to follow and encouraging selective or limited exposure to certain content, feeding back certain beliefs and behaviours [9]. An example of this is content related to the idealised representation of excessively thin bodies [‘thinspiration’]; exposure to this content has been found to be related to the severity of symptoms in people with ED [10].

In a recent study [11] on sources of health misinformation on the Internet, including misinformation about eating disorders, the authors warned of the echo chamber effect that online anorexia and bulimia nervosa communities promoting pro-eating disorder identities have on their members. Another study [12] describes these communities as authentic shared worlds for their members, which support and sustain the epistemic and affective dimensions of anorexia nervosa, as well as the role they play in maintaining the disorder through their intersubjective dimension and echo chamber effect. Evidence has also been found for this effect on pro-anorexia communities on Twitter as opposed to communities that support efforts to recover from the disease. Members of pro-anorexia communities tend to interact more closely with each other than healthy communities, and their interactions are more characterised by negative emotions [13]. Online communities’ characteristics of social networks such as Twitter and Facebook provide people at risk for an eating disorder with anonymity, social support and information related to the disease [14, 15].

3. Problematic use of the Internet and eating disorders

In Spain, according to the results of the aforementioned study [2], 33% of adolescents [mostly girls] are reported to be developing problematic use of the internet and social networks. Problematic internet use is used instead of the term addiction, as internet addiction is not currently scientifically defined as such in the main disease classification manuals, such as the DSM5 or the ICD-11. Moreover, the term problematic internet use is a neutral term that places the focus of the problem on the user and possible misuse of the internet rather than on the internet itself [16].

The International Association of Child and Adolescent Psychiatry and Allied Professionals [IACAPAP] defines this behaviour as an exaggerated preoccupation with Internet use, experienced as irresistible for longer periods of time than expected, and which is accompanied by significant distress or behavioural impairment caused by this abuse in the absence of other psychiatric pathology that could explain the excessive Internet use [17].

On the other hand, some of the psychological factors of vulnerability to problematic internet use [18, 19] are consistent with factors related to the risk of developing EDs [20, 21, 22, 23], such as low self-esteem, body image dissatisfaction and mood disorders such as depression and anxiety.

Thus, it is easy to conclude that universal access to the internet by adolescents, problematic internet use and the coincidence of risk factors form the ‘perfect storm’ to consolidate the association between social network use and EDs, which has been the subject of research for more than a decade.

Some recent studies support different aspects of this association, such as the existence of a clear relationship between body image, body preoccupation, body dissatisfaction and EDs among adolescent female students [24]; the increased likelihood of presenting with CD due to the greater number and frequency of social media use [25]; the relationship between healthy eating communities on Instagram, their intensive use and the prevalence and increased symptoms of orthorexia in their members [9]; the existence of a significant direct relationship between the frequency of social media use and the risk of developing EDs [26]; the immediate negative effects on young women of exposure to pro-anorexia websites [27] or the relationship between problematic internet use and EDs [28, 29, 30].

4. The control of harmful online content: the case of the European Union and Spain

In addition to the problematic use of social networks by adolescents at risk of suffering or already affected by EDs, the control of harmful content related to these disorders has been a recurrent concern and a long-standing demand of all sectors involved in the fight against EDs, which have traditionally experienced with anguish how the apology of anorexia and bulimia are easily and abundantly available on the Internet since they cannot be criminally prosecuted as they are not considered criminal content.

In this respect, a clear distinction should be made between these and so-called harmful content. Illegal or criminal content is delimited in a civil or criminal law norm [mainly criminalised in criminal codes, or considered contrary to fundamental rights such as honour and self-image in civil law].

Harmful content, on the other hand, is content that is considered likely to cause physical or psychological harm to those who consume it, but is not defined as a crime in the Criminal Code or does not meet the requirements for punishability; and which is usually grouped together in so-called dangerous online communities [groups of people with common interests, their own identity on the Internet and difficult to control].

However, the consideration of harmful content does not have a clear reference, as may be the case with the conduct defined as a crime in the various criminal codes, and is imprecise and open to interpretation, which poses risks to legal certainty [31]. As early as 1996, the European Union alluded to the difficulty of identifying and classifying online content likely to harm minors and indicated that the consideration of harmful content depends on cultural differences and that each country must therefore decide where the, sometimes fine, line separating it from illegal content lies [32]. This issue has been a burden on the various attempts to solve the problem up to the present day. Meta, one of the giants of the social networks and owner of Facebook and Instagram, considers this issue one of the four ‘key questions’ that it develops in its recent white paper on the regulation of online content [33], alluding to the thorny relationship with fundamental rights such as freedom of expression and opinion, deriving the responsibility for content moderation to governments, given the complexity of its consideration as harmful [34].

However, UNICEF includes in the category of harmful content that may contribute to aggravate eating disorders such as anorexia and bulimia because of their capacity to harm the development or endanger the right to health of children and adolescents [35]. According to this conception, content such as advocacy of anorexia and bulimia, promoters of the lifestyle known as ‘thinspiration’ or similar groups and online communities of ‘Pro Ana and Mia’ movements and extreme diets, would therefore fall into this category.

References to the fight against harmful content have been constant in the European Union’s internet regulatory framework since the first Communication mentioned above. In 2012, it mentioned the need to protect minors from illegal and harmful content in the ‘European strategy on making the internet more suitable for children’ [36]. In 2017, it called on online platforms to strengthen measures to combat illegal and harmful content online [37]. In 2018, it drew up a recommendation on measures to effectively combat illegal content online [38], and in 2020 it included this issue in its Proposal for a Regulation on the Digital Single Market for Digital Services, better known as the Digital Services Act [39].

In Spain, the most important initiative is Law 34/2002, of 11 July, on information society services and electronic commerce, which imposes on service providers the obligation to inform about existing tools for filtering and restricting access to certain Internet content and services that are unwanted or may be harmful to young people and children [40], subsequently supported by other legal regulations [41, 42]. However, the aforementioned legal vagueness of ‘harmful content’ prevented a real application of the law. An example of this is the Study on Social Networks approved by the Congress of Deputies in 2015 [43], which devotes a section in its operative part to harmful content and recommendations for its control, without defining it as such or even proposing its conceptualisation.

Various groups involved in the fight against EDs have been fighting for the clear legal regulation of harmful content on the internet related to these disorders. Thus, the APE Foundation in Spain, after several years of efforts in this regard, 2017 succeeded in presenting to the Aragonese Parliamentary Bureau a Proposition of Law, supported by all parliamentary groups, on the eradication of internet content and social networks harmful to EDs. The Dialogue Table for the Prevention of ED, co-led by the Catalan Consumer Agency and the Association Against Anorexia and Bulimia, achieved the modification of the Catalan Consumer Code in 2019 to include as a serious offence the activities of promotion, advertising, offer or any other activity that encourages or induces consumers to adopt habits related to eating disorders, such as anorexia and bulimia among others [44, 45].

This being the case, we had to wait until the publication of the new Organic Law 8/2021, of 4 June, on the comprehensive protection of children and adolescents against violence [46], to finally find a clear tool for the fight against harmful content related to EDs. This legal norm obliges public administrations to promote the implementation and use of parental control mechanisms to protect minors from the risk of exposure to this content [Art. 46], including the inclusion in the Penal Code of a new article 361 bis that punish ‘the distribution or public dissemination through the Internet, telephone or any other information or communication technology of content specifically intended to promote or facilitate, among minors or persons with disabilities in need of special protection, the consumption of products, preparations or substances or the use of techniques for the ingestion or elimination of food products whose use is likely to generate a risk to people’s health’.

This new criminal classification of the apology of ED is undoubtedly an important step forward in this area, although its practical application presents important difficulties, such as the fact that most of the people who produce, distribute or share this content belong precisely to the sector of the population it is intended to protect: young people and adolescents who suffer from one of these ED; or the progressive displacement of the publication of this content from websites to social networks and from these to instant messaging applications, where the control of the dissemination of content is very complicated.

5. The fight against ATTs on the Internet: some proposals

Given the difficulties of effective repressive control of harmful content related to ATTs by governmental authorities, measures to prevent and educate users about these risks seem more easily applicable, although their real effectiveness is unknown.

In 1999, the European Union established the so-called Safer Internet Plan, which under different names and in different phases evolved into the current initiative called ‘Better Internet for Kids’ [47], which includes help and information lines for children and adolescents on dangerous communities ‘Pro-Ana’ and ‘Pro-Mía’, and which in Spain is managed by the National Cybersecurity Institute [INCIBE] through its IS4K Internet Segura for Kids programme [48].

The most important Internet service providers have been implementing measures to control the dissemination of ATTs beyond the possibilities of active protection that users themselves can implement on their devices through the wide range of parental control applications and configurations available, with the introduction of specific algorithms for the establishment of filters for this content based on the creation of keyword dictionaries. Thus, when search engines detect these words or hashtags, they provide the user with a warning message about the risk of search-related posts and the link to help services in this respect, but still offer the possibility to access the searched content.

Similarly, they have implemented specific information about these disorders on their support pages, including help resources [49, 50, 51] and even directly prohibited the publication of content that promotes eating habits that may have adverse health consequences [52, 53].

In this line of the fight against harmful content on the Internet related to eating disorders, the APE Foundation for the prevention and eradication of EDs has promoted the development of a computer tool for the early detection of apology of EDs on Twitter in collaboration with the University of Zaragoza. The project, currently under development, is based on monitoring key hashtags using natural language processing techniques to identify harmful messages in the context of ATTs, allowing the detection of accounts that disseminate such content for reporting. It also includes a tool for analysing the interaction between active accounts, and identifying communities of users, which would help in the prevention and early detection of these disorders [54].

6. Conclusions

The internet and social networks have become powerful means of communication for adolescents. Problematic use of internet is related to a higher risk of suffering from these disorders in this population segment, which is why the control of harmful content related to the promotion of EDs is an objective of public administrations. However, the lack of legal definition of this content has hindered its possible control. Nevertheless, the European Union is working on the issue through different legislative instruments and Spain has recently criminalised these conducts, which, despite being a clear advance in the matter, poses significant difficulties in its practical application; therefore, in parallel, different areas have been working on measures for prevention, information and support for people affected by these disorders.

Acknowledgments

We thank APE Foundation for its interest in fighting against the spreading of eating disorders in the Media. Its activities aim to reduce the influence of those Media among adolescents, thus reducing the number of new eating disorders patients.

Conflict of interest

The authors declare no conflict of interest.