Image via Netflix

A third of the way into the 1981 ABC movie The Best Little Girl in the World, lead character Casey Powell steps onto the scale at the doctor’s office. She weighs nearly 83 pounds and so far, we’ve seen Casey, played by Jennifer Jason Leigh, throw up food, ditch meals entirely, and exercise in her bed at 3 a.m.

“I want Casey to see a psychologist,” the doctor tells her mother, who seems confused. “Anorexia nervosa, self-starvation,” he continues. “Usually found in an adolescent who feels she has no control over anything in her life so she denies her hunger in order to have control over at least one thing: her body.” So begins a somewhat smarmy monologue from the doctor about the problem with fashion models (“they look like six-week-old cadavers”) and facts about girls dying from anorexia, as a sullen Casey sits in silence.

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The year of the film’s release, Jane Fonda had just revealed her struggles with bulimia in her wildly popular Workout Book, Karen Carpenter was still alive, and the sitcom Growing Pains had not yet introduced Tracey Gold to household audiences. Eating disorders were still a complicated, elusive subject. And The Best Little Girl In The World, while being overwrought and tantalizing, full of screaming matches and maudlin music cues, was one of the first movies not only to dramatize anorexia, but to try to explain it.

The first movies about eating disorders were explanatory for a reason: people were just learning that they existed. The 1970s saw a sharp increase in cases of anorexia diagnoses due to the popularity of studies during the decide such as psychoanalyst Hilde Bruch’s case studies—like Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within—which brought the disorder into the spotlight. The first formal medical paper on bulimia nervosa was published in 1979, and was described as being connected to anorexia.

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Movies about EDs would take their inspiration from this rise in new psychoanalysis on the subject, with The Best Little Girl In The World based on psychotherapist Steven Levenkron’s fictional book of the same name. In her book The Lifetime Network: Essays on “Television for Women” in the 21st Century, co-written with Emily Witsell, Texas A&M University art historian Emily Newman wrote about how these early television movies were tools to educate the public on eating disorders and treatments. And even into the 1990s and 2000s made-for-TV eating disorder movies would follow a very specific formula, usually with a character being told they’d look good losing a few pounds, gleaning tips from friends, falling into a cycle of purging or starving before being hospitalized and perhaps watching a friend die (as it happens in The Best Little Girl In The World and the 1986 movie Kate’s Secret).

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“Those early TV movies really did not want to glorify [eating disorders,]” Newman says. “Characters work very hard and often have main characters die or careers being ruined, especially if it’s a dancer or gymnast. It’s to say: this is a really bad choice almost to the point where it’s over the top.”

While influential movies about eating disorders still cropped up in the 1980s and 1990s, such as 1989’s The Karen Carpenter Story or Tracey Gold’s For The Love of Nancy (which was based on her own real-life, high-profile struggle with anorexia) they were still only TV movies relegated to women’s channels. “I hope people won’t say, ‘Oh, another one of those women’s pictures,’” Meredith Baxter-Birney, who played the title character in Kate’s Secret, told the LA Times in 1986. “We want to cross that line and get men to watch ‘Kate’s Secret’ and not think, ‘Stupid broads. It’s all about being skinny.’”

“What we have here,” read a critical review of For The Love of Nancy in People, “is a disease-of-the-week drama.”

Since then, attempts to understand eating disorders have become more common in pop culture. And yet, movies that extensively explore eating disorders outside of those made for TV are still bafflingly rare. Which is why it was surprising to see the new Netflix movie To the Bone, which stars Lily Collins as a sardonic young woman struggling with anorexia at a rehab center, and inspired by writer and director Marti Noxon’s own experiences. While its narrative is familiar at its surface, its existence, as a Hollywood production with a high-profile cast and director, is exceptional.

The prevailing idea that movies about eating disorders are cheap melodrama that only deserve to be shown on women’s channels like Lifetime was one Marti Noxon had to push up against to even get To the Bone made—and undoubtedly one of the reasons there aren’t many movies on the subject. Male studio executives told her that it was a “disease movie nobody wanted to see” and that it was too small a topic. “Throw a rock in your office and you’ll hit a woman who is harming herself one way or another,” she told Vulture.

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Even as teen movies flourished in 1980s and 1990s, eating disorders were never a narrative centerpiece—often just a fleeting, colorful character trait, in mainstream productions that were for the most part written by men. “Grow up Heather, bulimia is so ‘87,” Heather Chandler sneers at Heather Duke while she pukes in the bathroom in the 1988 comedy Heathers. And yet from 1988 to 1993 incidences of bulimia in women age 10-39 would triple.

If the 1980s was for earnest, educational approaches for depicting eating disorders, the heroin-chic ‘90s was the time for its fashionable glamorization. The decade gave audiences memorable albeit unrealistic characters like Brittany Murphy as Daisy in Girl, Interrupted (who couldn’t eat in front of people and only ate rotisserie chickens); Clueless’s casual anorexic Cher Horowitz; and the quietly bulimic Kathyrn Merteuil in Cruel Intentions. All of these depictions intensified the long-standing misconception that eating disorders are a problem for only thin, preppy, rich white girls.

Even though To the Bone is based on Marti Noxon’s real-life story, when the trailer was released mental health experts were upset to see yet another sick, rich white girl in what appeared to be a quirky rehab comedy. The film’s main character Ellen is a snarky 20-year-old illustrator, the kind to tell fellow patients to “suck her skinny balls,” and when we meet her she’s already cycled through several treatment programs. Her father is absent, always off at work, and her biological mother lives in a different state and has accepted her daughter wants to die. Ellen is raised by her kind but overbearing stepmother, who is the only adult in her life who isn’t tired of dealing with her anorexia.

Ellen does fit the stereotypical mold when it comes to characters with EDs: pretty, white, well-off financially, and most importantly suffering from anorexia. “There tends to be a focus on extreme thinness but that’s not a reflection of the reality and diversity of the people who are truly affected by eating disorders,” says CEO of the National Eating Disorders Association Claire Mysko about the stereotypes typically seen in movies about eating disorders. Most of the calls NEDA gets, Mysko says, are from people who aren’t sure if they have an eating disorder because they aren’t shockingly thin, anorexic, or bulimic, all of which overwhelm medical studies and pop culture depictions of EDs. “There are people who struggle at all body shapes and with a range of sizes and those aren’t reflected in the stories about eating disorders that we see,” Mysko says.

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Even though To the Bone does focus primarily on Ellen, the rehab house she stays in is an attempt at diversifying the picture of an eating disordered person. The inclusion of Kendra, a young black woman who’s bulimic but fat, and Luke, an anorexic ballet dancer and manic pixie dream boy-type, is refreshing. Still, the majority of To the Bone, like so many ED movies, is about that search for extreme thinness Mysko mentions, as characters obsess over weekly weigh-ins and the calorie counts of feeding tubes. Soon after we first meet Ellen she displays her talent for calorie-counting, her step-sister quizzing her about how many calories are in butter, bread, and boogers.

The hope is that movies about eating disorders depict them realistically, showcasing the diversity of the disorders and not falling intro tropes. But in an effort to portray the realism of EDs, movies can potentially run the risk of glamorizing them or, worse, teaching vulnerable viewers tips and tricks. “This film is supposed to make you not be anorexic,” Christina Ricci told Rolling Stone in 1996 about her experience watching For the Love of Nancy. “But I was like, ‘Damn—good drama.’ So I sort of willed myself into it.” A filmmaker might make her characters funny and likable because she wants them to be more than their illness, but then people conflate the two. Characters like Cassie Ainsworth from Skins, Blair Waldorf from Gossip Girl, or To the Bone’s Ellen might be painted with such a familiar and likeable brush that they might inspire girls to be just as skinny. (In one plot point in To the Bone, Ellen’s artwork of her own body becomes popular with thinspo communities on Tumblr, and a young fan of hers starves herself to death.)

“In a lot of depictions I’ve seen there’s a lot of detail in eating disorder behavior and if someone’s at risk we caution against that,” Mysko says, citing NEDA’s guidelines on sharing storylines about eating disorders which also advice against showing characters at their lowest weight. “Using numbers and calorie counts can be problematic for people who are actively struggling or at risk.” Aside from the calorie scene, we never learn the exact weight of Ellen or her housemates (Noxon reportedly removed these figures from the final cut) though we do see her body often, and in one dream sequence Collins appears digitally altered to be near-skeletal. Rather than meet Ellen, as so many movies and TV shows have done, at the point where she begins to slip into anorexia, we meet her in the middle of an ongoing struggle.

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Film is constrained by length in a way that television isn’t, which adds to the challenge of portraying the reality of an eating disorder. “In being serialized, television may have a greater ability to try and deal with the problem seriously because it isn’t over and done within an hour and a half,” says Su Holmes, a Reader in Television at the University of East Anglia with a concentration in anorexia in pop culture, citing Hannah Ashworth’s storyline over several years on UK soap opera Hollyoaks as an example. “It’s weeks, months, sometimes decades.” In To the Bone Noxon gives us a small snapshot of Ellen’s sickness: we don’t see her become an anorexic person, and by the film’s end we don’t see her cease to be one either.

But if you’re going to make a film about eating disorders, how do you do it? The history of characters who misrepresent the wide spectrum of eating disorders, glamorize EDs, and might even inspire women to develop them complicates the question. But the answer may lie not in a grand unified explainer of eating disorders, but in telling a specific story of a specific person with an eating disorder. Whether fairly or not, a movie like To The Bone—the rare picture about ED written and directed by a woman about her personal experience—is expected to move the genre forward. And while To The Bone still trips on some of the same mistakes of past films in the ED genre, its glossy, high-budget existence feels like a small, non-sensationalized step forward for dramatized eating disorder narratives.