Pressure to Be Perfect

updated 07/26/2004 AT 01:00 AM EDT

originally published 07/26/2004 AT 01:00 AM EDT

When Mary-Kate Olsen's family announced four weeks ago that she had entered treatment for an eating disorder, many fans weren't surprised. Photos of the actress in recent months had pictured an alarmingly thin girl with stick legs and sharp shoulder blades.

What's most surprising is that, to some fans, those photos weren't alarming, but inspiring. "I admire her," wrote one 19-year-old girl about Mary-Kate's increasingly gaunt appearance on a teen Web site's message board devoted to eating disorders. The girl had cut out the skinniest pictures of Mary-Kate, she wrote, "and pasted them in my journal, because that is what I am striving to look like." Indeed, to the message-sender and others like her, Mary-Kate "epitomized the perfect 18-year-old," says Dr. Allyson Cherkasky, clinical director of eating-disorder services at Walden Behavioral Care in Waltham, Mass. "She's very thin and very beautiful and represented having it all."

Surrounded by images of young celebrities who are painfully thin—or very slender with improbably large breasts—girls growing up today can feel immense pressure to meet the same standard. Trying hard to look like their idols, some fall prey to eating disorders, and some abuse drugs to help them lose weight. Others, familiar with TV shows like Extreme Makeover and The Swan that make physical transformation look so easy, turn to plastic surgery. According to the American Society for Aesthetic Plastic Surgery, 11,326 girls aged 18 and under got breast implants last year—triple the number from 2002. "These glamorous teen celebrities seem to have it made," says Dr. Susan Sabin, site director of the outpatient program at the Renfrew Center in Philadelphia. "It appears that their lives are trouble-free, happy and constantly entertaining—and the vehicle to all that is a perfect, skinny body."

Ironically, young celebrities themselves are hardly immune from the pressure. "In this industry it's at a huge, elevated level," says The Sopranos' Jamie-Lynn DiScala, 23, who suffered from anorexia and now works as a spokeswoman for the National Eating Disorders Association. "When you're sitting in an audition waiting room, how can you not look at every other girl around you and start comparing yourself?"

Jessica Simpson, whom young girls often mention as someone they want to look like, says she struggles with her own body image. "I've been there, trust me," says the pop star, 24. "When I was younger, I tried to be skinny. There is so much pressure in today's society to look like the girl on the cover of the magazine. But [those photos] are airbrushed and have special lighting. She's gone, through two hours of hair and makeup. That just sets expectations really high for young girls."

For this age group, aspiring to unrealistic standards can lead to self-doubt, depression, extreme dieting—and in some cases, eating disorders. Dr. Sabin says many of her patients idolize one young TV star who is "extremely, frighteningly thin. But she hasn't been referred to as having an eating disorder. She's admired. The anorectic image is glamorized."

Because many cases go unreported, the statistics vary, but 5 million or more girls and women in America are estimated to suffer from anorexia and other eating disorders. According to the federal Office on Women's Health, eating disorders are increasing, especially among young white females, including preadolescents. While anorexia is relatively rare—affecting up to 3.7 percent of the female population at some point in their lifetime—it is the most deadly of all mental diseases. About 5 to 10 percent of anorexics die from it or its complications.

One factor that makes eating disorders particularly dangerous is drug use. "Substance abuse is a bad mix with anorexia nervosa," says Dr. David Herzog, director of the Eating Disorders Program at Massachusetts General Hospital in Boston, who is conducting a long-term study of 246 women with anorexia and bulimia. "It was the strongest predictor of death in our sample."

And yet the National Center of Addiction and Substance Abuse at Columbia University estimates that up to 50 percent of individuals with an eating disorder abuse alcohol or illicit drugs. Girls with a desperate desire to be skinny sometimes turn to stimulants like cocaine and amphetamines to suppress their appetite and increase their metabolism.

"It's become a very significant issue," says Dr. Ira Sacker, director of the adolescent-medicine program at Brookdale Hospital in Brooklyn. "I didn't see it much 10 years ago, but now I'd say about one in five of my patients are using some kind of drug."

While achieving a waifish physique is a prized goal for many "tweens," aged 8-12, older girls often feel obligated to achieve the silhouette of stars who are both thin—and big on top. A revealing photo of Lohan earlier this year sparked talk that she'd had implants, which she categorically denies. King Arthur star Keira Knightley, 19, dark haired with a slim figure, admits that there is "a lot of pressure to conform to a certain type. It starts going into your subconscious that you should be blonde, have big breasts and all of that."

Most board-certified plastic surgeons say they usually won't perform implant surgery on girls under 18 unless one breast is much smaller than the other. Girls finishing high school, though, often request—and get—implants as graduation gifts.

Teens are having other cosmetic procedures, such as botox injections and eyelid surgery, in greater numbers too. But plastic surgery carries risks, particularly for teens. "Their bodies are not done transforming and changing," says Dr. Lawrence Bass, a board-certified plastic surgeon in New York City. "It's like building a house on quicksand—the foundation isn't stable."

Try telling that to a young girl who believes the route to happiness is looking perfect, just like her favorite stars. Or maybe she'll listen to one of them: "There is always pressure, for anyone, everywhere," says actress Mandy Moore, who turned 20 in April. "But I am who I am, and I'm not going to change to fit some stereotype. I really, really don't care."

Jennifer Wulff. Allison Adato, KC Baker, Mark Dagostino, Kathy Ehrich and Debbie Seaman in New York, Tom Cunneff, Sean Daly, Alison Singh Gee, Kwala Mandel and Brenda Rodriguez in Los Angeles, Giovanna Breu and Kelly Williams in Chicago, Wendy Grossman in Austin and Sara Hammel in London

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