"I opt for the local anaesthetic, partly because it’s slightly safer... but mostly because I feel like I should experience the fear and the pain."

"The overwhelming pressure placed on women to conform to unrealistic body shapes is clearly a bad thing in and of itself."

Weight can become your whole world in anorexia. You, your family, your friends and doctors focusing with increasing desperation on every gram lost and gained.

But new research has found people with severe and treatment-resistant anorexia may actually fare better if their doctors stop trying to get them to gain weight – instead trying to improve their quality of life and treat depression and other symptoms.

The finding is counter-intuitive because we think of eating disorders as primarily disorders of body image – triggered by skinny models on catwalks or unrealistic representation of women.

I often cringe just a little bit when I hear them used to justify criticism of sexualisation or women and unrealistic body images in advertising and media.

The overwhelming pressure placed on women to conform to unrealistic body shapes is clearly a bad thing in and of itself. As feminists (or, if you’re scared of the “F” word… as women and men who believe women should be portrayed realistically and not have their bodies fetishised for commercial gain) we have good reason to complain about they way women’s bodies are commoditised.

But sometimes I wonder if the constant links made between these images and eating disorders might end up misrepresenting – or even trivialising – conditions like anorexia, which is the most deadly psychiatric illness and kills one in five sufferers.

“There is still an enormous stigma and widespread belief [eating disorders are] … a lifestyle choice,” says Anthea Fursland, the president of the Australia and New Zealand Academy of Eating Disorders.

You can’t help wondering if the perception that eating disorder sufferers are just 'difficult' women who have taken their obsession with body image too far is behind the vast shortage of treatment available for them.

In his book “Crazy Like Us”, Ethan Watters argues anorexia as we know it is better understood as a way of expressing pain that is deeply embedded in our culture and history.

He describes how anorexia went from an incredibly rare disorder in Hong Kong to an epidemic seen in similar proportions similar to the rest of the Western world.

In the 70s and 80s in Hong Kong eating disorders were incredibly rare, and when women did get sick with them they almost never explained their food refusal in terms of a fear of weight gain or body dysmorphia. Instead, they talked of feelings of fullness or physical difficulties swallowing.

“Most assume that anorexia, with its attendant fear of fatness and body dysmorphic disorder, is born of a peculiar modern fixation with a slender, female body type, and that popular culture transmits this fetish to young women,” he writes. Yet in Hong Kong, despite the rise in sexualised images of women fettishising skinny models, there had not been a rise in eating disorders.

Watters traces the eventual explosion of the western version of the condition to the tragic death of a 14 year old girl, Charlene Hsu Chi-Ying, in 1994. After she collapsed on a public street, the media and charity groups took up the cause of anorexia, and the typical western symptoms relating to fear of fatness were highly publicised.

Before Charlene’s death, psychiatrists specialising in eating disorders saw only a few people a year. In the years after her death, studies indicated between 3 and 10 per cent of young women could be suffering from classic anorexia nervosa.

That’s not to say that these women were choosing to develop anorexia – far from it. Just that their psychological pain was being funnelled through a new framework.

As this case study of a young Sri Lankan man who starved himself almost to death shows,  refusal of food can have complex origins.

Some eating disorders are undoubtedly triggered by living in a society where women are constantly subtly told that their most important value lies in having a body that fits a narrow stereotype.

But for many people with anorexia – particularly the 30 or 40 per cent of cases that are treatment resistant – the underlying psychological problems are still poorly understood.

“People make the mistake of assuming all anorexia nervosa is the same, and it’s not,” says Sydney University’s Stephen Touyz – the author of the study that found doctors may need to stop focusing solely on getting patients to gain weight.

And each case occurs against a complicated background of genetic risk, environmental and social triggers, and the support (or lack thereof) the person receives throughout their illness.

Anthea Fursland says it’s important to understand that particularly in long-term cases, anorexia “isn’t about being thin or attractive, it’s about staying in control and a fear of losing control and a number of other things.”

 “In the middle ages it is now thought some of the saints were anorexic and that wasn’t about weight and shape, it was about purity,” she says. “The cultural context determines how the anorexia is understood by both the sufferer and the people around them.”

Skinny models can’t be helping the situation, but they will never explain the whole story.