Abusing the Body: Psychological Abuse? The Bioethical Aspects of the Fashion Model Profession

The slimness ideal plays an important role in the sociocultural background of eating disorders. The risk of anorexia nervosa and bulimia nervosa is high among fashion models, because in the beauty industry the thin body is a professional requirement. The first author of the present self-case report had anorexia nervosa from her age of 15 years, between 2006 and 2013. However, she was employed as a fashion model between 2008 and 2013. The pressure to maintain the slimness was intensive; the contract included the breast-waist-hip circumference as well. The case report is illustrated by excerpts of the personal diary. Although a regulation was brought in by which models with a body mass index lower than 18 cannot be employed in the fashion industry, the agents pressed her to drink water to reach the necessary limit. The agents often criticized the models’ body in a rough manner and force them to be slim. This pressure is an everyday phenomenon in the fashion industry, and is harmful for the physical and mental health of the models. The impact of fashion industry representatives on models is can be regarded as a form of psychological abuse, although the models (and the parents, if the models are minors) accept this way of life. This is a subconscious collusion among the model agencies, the parents and the models. Because of the risk of psychological abuse, an international regulation is recommended in the employment of fashion models.


Introduction
Sociocultural influence plays an important role in the background of eating disorders that occur in psychiatric practice more and more often. The cultural pressure of the thin ideal and vicarious learning have a role in the development of eating disorders. The thin models are primarily imitated by young people, though the whole culture is imbued with the fashion of thinness.
Fashion models are thought to be at an elevated risk for eating disorders, but few methodologically rigorous studies have explored this assumption. Body image issues associated with eating disorders involve attitudinal and perceptual components: individuals' dissatisfaction with body shape or weight, and inability to assess body size correctly [1]. While prior research has mainly explored social pressures produced by the media, fashion, and advertising industries, this paper focuses on the effects of personal networks on body image, particularly in the context of internet communities [1].
The risk of developing eating disorders is very high in certain jobs e.g., among flight-attendants, gymnasts, ballerinas, jockeys. Fashion models live in a world where being thin is a professional requirement. According to an Italian survey, there are more signs related to eating disorders among fashion models in comparison to their control group. Five percent of fashion models reported having had eating disorders in the past [2].
The appearance pressures experienced by fashion models have been criticized as harmful to their health, as well as increasing eating disorder risk among youth by promoting ideals of extreme thinness [3]. Approaches providing employment protections and healthier working conditions are most supported by professional models [3]. These findings help to illuminate viable policy approaches from the perspective of key stakeholders [3].
In a recently published book entitled "Size zero: my life as a disappearing model" Victoire Dauxerre, an ex-model describes her personal experiences about the world of fashion models [4]. According to her, today's fashion show models are like clones, all girls are the same size, they are not allowed to show their personality, they do not give life to the clothes they are wearing. They are given special instructions on avoiding eye contact with the audience, they are not to move their hips, their facial expressions must be neutral, and they should present the clothes in the simplest way. According to the account of the author, the casting directors often use shaming if they notice a bigger size than desired (e.g., hip size greater than 90 centimetres, regardless of body height).
Understanding the cognitive processes underlying body dissatisfaction provides important information on the development and perpetuation of eating pathology [5]. Previous research suggests that body-dissatisfied women process weightrelated information differently than body-satisfied women, but the precise nature of these processing differences is not yet understood [5].

Personal Experience -Self Case Report
The first author (N.B.) worked as a model in the fashion industry between 2008 and 2013. She had suffered from anorexia nervosa (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013). Her agents were aware of her illness; however, they hired her. The contract included her breast-waist-hip circumference that she had to keep an eye on. This restriction became an obstacle in the therapy and her recovery, and it was an illness-maintaining factor. Despite her agents being satisfied with her measurements she was experienced constant body dissatisfaction. Everyday, fasting and eating less than 1000 kcal per day became a habit, and this was accompanied by many hours of physical exercise on a daily basis. Her meetings with agents were usually preceded by long distance running or other physical exercise without energy supplement. It was always a great stress to have new photos taken, so that everything would be perfect because even if the measurements were good, they always found some criticisable physical characteristics. One of the agents found her nasal bridge too wide and he suggested plastic surgery for the sake of a brand.
Below we present excerpts from the personal diary of the first author. In 2007, a regulation was brought in by which models with a BMI lower than 18 cannot be employed in the fashion industry. When the author was at a fashion week in Madrid she experienced a premeditated evasion of this ruling. She noticed all girls were being measured by their agencies, their BMI was calculated, which was very often lower than 18. Since they did not have to remove their clothes when their weight and height was being checked, there were plenty of opportunities for deceit. Many fashion models fastened weights around the waist. The author, being five kilograms below that required to reach a BMI of 18, -advised by the agent -drank five litres of water within 15 minutes. The author did this because she feared for her career as a fashion model. She was 18 years old at the time.
Meeting expectations is difficult; the agents often make derogatory comments about the body shape of perfect models even at the peak of their career. The author was often questioned about the circles under her eye and her dry hair that were probably signs of physical exhaustion and undernourishment. It was very disturbing to hear comments regarding the circles under her eyes that proved difficult to eliminate. There were also agents who advised her to treat them with haemorrhoid cream. Models who had their monthly period were not allowed to attend casting calls because their face seemed puffy, their bust seemed larger, and their skin, apparently, looked less beautiful.
The first author (N. B.) quit modelling in 2013 and started her studies at Semmelweis University, in Budapest. She overcame her eating disorders, maintains a healthy weight and her eating habits have since normalized. While in school, she contacted the Institute of Behavioural Sciences with her story and started working with the second author (F. T.) on studying the correlation between eating disorders and high fashion models. She aims to persue a career as a PhD. student after graduation.

Discussion
Sustaining the thin ideal is a cultural phenomenon, a segment of which is the fashion profession. Presumably it is a circular causation: on the one hand, the agents and fashion designers follow the existing fashion, on the other hand they shape/alter fashion. However, they have responsibility whatever the motive may be. They are the ones who require a specific body shape, and often they favour young girls with an 'anorexic' appearance, or they goad models into losing weight by using various healthlimiting methods. The fashion profession tries to cover up the obsession with thinness as if everything was alright with the body shape of the girls, and as if that was a personal endowment. Of course, such thin fashion models do exist in reality but they represent only a small percentage of the total. In our previous study, out of 30 respondents only two stated that their thinness was natural [6].
It is unambiguous that the representatives of the fashion profession, the agents, the designers, and the casting directors strongly influence the weight of the models in order to reach the lowest possible weight. so-called e-commerce webpage to use virtual figures to present clothing online in order to save the costs of hiring a model. These further increase the unrealistic body image ideal promoted by the industry through fashion models.
The fashion designers design fashion clothing for extremely thin body shapes. They are influenced by market forces. It can be attributed to the change of cultural ideals that the sales index of certain fashion houses has indicated growth when their clothing is advertised on super-thin models. If customers boycotted the purchase of clothing because of the employment of thin models, the marketing strategies would have to change promptly. Due to the already accepted thin ideal in the culture, this is unlikely to happen.
The change in the value of human body is one of the characteristics of today's culture. Nowadays the human body is often used for business purposes. Everyday examples are the beauty industry, the fitness industry, plastic surgery, sexism. Considering their health damaging effect, the fashion industry could be one of the self-destructive tendencies of Western civilization.
At the same time, the cultural environment does not constitute an exemption in deliberately sustaining the clearly pathological phenomena. The impact of fashion industry representatives on models is often characterized by psychological abuse: imposed weight loss, humiliation, withdrawal from the contract, emotional pressure. They bear responsibility for the changes in the health status of fashion models.
The fashion industry forces unrealistic requirements on models. This is already manifested at their selection: they often employ anorexic girls. Moreover, they are forcing models who do not meet their requirements to have a pathologically thin body. In many cases these requirements can be met with selfmortification: pathological eating habits, intensive physical exercise by which the only purpose is to burn calories.
According to Dauxerre [4] the fashion models work in a system based on fear. One face represents the brand only for one or two seasons, and the model can be replaced any time. Therefore, if someone wants to work with a given brand, she has to bear adversity. It became a widespread viewpoint that models should feel honoured when given the opportunity to wear the designers' fashion clothing and when they are included in their fashion week and shows.
It is important to emphasize that in general the models -at least at the beginning of their career-are minors. This also makes parental consent necessary. It seems that there is a kind of subconscious collusion among the model agencies, the parents and the models. Parents also accept the requirement of the pathologically thin body because of social success (to be known, to assume the role of a star) and high income. These are also the reasons why fashion models undertake to manipulate their body. However, this constitutes no exemption; these are similar to rape cases where minors are said to have agreed to intercourse.
The propagation of the thin ideal increases health risks. Therefore, a standard control system should be set up for the employees of the beauty industry that excludes the unrealistic requirements and ensures the comprehensive physical and mental health of fashion models. This is important from an epidemiological point of view as well since it has an impact on the general population through the effect of modelling and imitation.
Just as in sports, doping entails disqualification for the sake of health promotion supported by an accurately developed control system, the fashion profession can also introduce such strict controls.
It is worth considering the employment of fashion models above age 18, when as adults they can independently decide upon their career. The minors who are employed as models should be strictly regulated (e.g., in case of shows where children's clothing is presented). These regulations would meet with resistance in the legislation of certain countries. It would be good to know which countries have the capacity to overwrite business interests with health promotion. Therefore, an international consensus is recommended in this field of health promotion.
Further studies will be necessary to establish whether the slight excess of partial syndromes of eating disorders among fashion models was a consequence of the requirement in the profession to maintain a slim figure or if the fashion modelling profession is preferably chosen by girls already oriented towards symptoms of eating disorders, since the pressure to be thin imposed by this profession can be more easily accepted by people predisposed to eating disorders.