Pictures of sickly thin models and tips about how to hide her anorexia greeted Shannon Bonnette every time she surfed the Web five years ago.

Bonnette visited the sites out of curiosity more than anything else – after 15 years with an eating disorder, she didn’t need any tips.

But the girls on the sites were a community of sorts; they were all going through a similar illness, and all felt misunderstood. Bonnette, who is from Erie, Pa., and now lives in Conneaut, Ohio, even started her own Web site, where she kept a journal of her experiences dealing with anorexia.

She would get e-mails from people who supported her honesty in talking about her site, even though it was difficult to read.

Bonnette, who now runs a Web site to support people recovering from eating disorders, has been on both sides of a controversy that has been building over the past few years with the growth of “pro-ana” and “pro-mia” Web sites that promote, respectively, anorexia and bulimia, and of Web sites that are geared toward recovery.

On one side are doctors who worry that these sites might trigger eating disorders in young people on the brink of the disease, or worsen the medical state of people who already have eating disorders.

On the other are the sites’ organizers, who argue that they provide a community for all those who feel isolated by their illness, and that warnings on their sites are meant to dissuade anyone who cannot handle their content.

That’s part of the problem with these sites: Doctors think they may perpetuate the illness, while visitors don’t see their problem as an illness at all.

“The very core of the belief that backs these sites is that eating disorders are a lifestyle choice and not an illness,” said Dr. Rebecka Peebles, an instructor in adolescent medicine at Lucille Packard Children’s Hospital in Palo Alto, Calif.

A disclaimer on one popular site reads: This is a pro-ana Web site. That means this is a place where anorexia is regarded as a lifestyle and a choice, not an illness or disorder. There are no victims here.

More damage to do

As a doctor who looks at the medical complications of anorexia, Peebles does not agree with this assessment.

She’s done some preliminary studies of the effects of these Web sites and suggests that they can be detrimental to the health of those who visit them.

Peebles and medical student Jenny Wilson surveyed 64 patients who had been seen for treatment of eating disorders and 91 parents of such patients. Although they acknowledge the sample size is small, they found that almost 40 percent of the patients had visited pro-eating disorder Web sites, and 38 percent had visited pro-recovery sites.

People who used the sites had more hospitalizations because of their eating disorder, and were spending less time on school work than patients who did not visit the sites. More than 60 percent of the patients who visited the pro-ana sites had learned weight loss techniques from the sites, and more than 30 percent of patients had learned similar techniques from postings made by other patients on the pro-recovery sites.

Peebles also thinks that these sites might attract teens in particular because many pro-eating disorder sites feature disclaimers warning the “weak-hearted” not to enter – a red flag of sorts that something is off-limits, and therefore, worth checking out.

“Less lost”?

But while the sites might affect some people negatively, Shannon Bonnette says they provided her with a valuable avenue of support.

Anorexia was a part of her identity that isolated her from others.

“I just figured it was the way I was going to die,” she said.

Her parents had taken her to the Cleveland Clinic for treatment, and she saw a counselor on her college campus, but she didn’t think that the doctors she talked to knew anything about eating disorders.

Even during the worst times of her illness, the ability to put her experiences on the Web were valuable. She says her postings were more real and gritty than what she read in the recovery community, where everything was focused on the positive.

“Therapists and doctors who think that they know it all, they don’t know it all,” she said. Because of the Web sites, “people going through it feel a whole lot less lost.”

It’s true that these Web sites can provide a community of sorts, and a place for people to share their experiences of going through a difficult disorder, said Stanford’s Peebles.

Eating disorders in general are isolating, she said, and often people who are ill are restricted from physical activities or school, and if they’re in treatment they spend more time at home, and inevitably, on the computer.

Peebles even has patients who cannot or will not express their feelings in person, but will refer her to their pro-ana Web sites where they write about what they’ve been up to.

Whether they provide support or worsen the medical conditions of people with eating disorders, the sites affect people in vastly different ways. Depending on whether a person is anorexic, or recovering, or on the brink of developing the disease, the sites could be a source of help or the trigger that plunges her into a deadly disease.

Free for all

But since they’re on the Internet, there’s no way to cater them specifically to a certain group of people, no matter how much the disclaimers on the sites might try.

While there are Web sites out there that promote eating disorders, and those that encourage the road to recovery, people with eating disorders often will go to the ones that support their illness because some, by definition, have mixed feelings about getting better.

“One of the diagnostic criteria for the illness is denial of the seriousness of the illness,” said Marsha Marcus, a psychiatry professor at the University of Pittsburgh School of Medicine. “By definition they are made anxious about thinking of relinquishing the illness.”

The sites might trigger eating disorders in vulnerable individuals, she said. While she doesn’t think that Web sites can cause or cure a serious disorder, Marcus knows that eating disorders stem from a complex combination of forces.

In some ways, the support they might provide is countered by the way they encourage people to stay thin or maintain an eating disorder.

Recovery case

Some sites, such as Bonnette’s, try to provide the support network without the negative aspects of other sites.

Strangely, it was a pro-ana Web site that helped her recover; after reading the complaints and journals of girls who just wanted to lose a few more pounds to get below 100 or 96 or 94, she just got sick of it all.

She began to realize that the postings never changed, and that no one ever got any better. With this thought, she started to give healthy eating a try.

But Bonnette’s case is by no means a common means of recovery from eating disorders. She was lucky – she is 26 now and gave birth to a baby this spring.

Her site now straddles a fine line – it isn’t pro-ana, nor does it constantly urge people to recover, she said. It doesn’t contain the pictures of thin models or the diet tips present on some sites, but it provides links to some of those sites, as well as sites that help people through recovery.

While her site has been criticized as being pro-ana, she thinks it is an invaluable source of information for people with eating disorders and those who want to discover. It’s not like some of the negative sites that are over-the-top, she says.

“There’s definitely a line,” she said. “As with everything, there’s a good and a bad.”