The first references to body image date back to the Paleolithic era, 30,000–20,000 B.C. This was demonstrated by the discovery of the Venus of Willendorf, a statuette of a woman symbolizing fertility in a village on the banks of the Danube. Currently on show at the Vienna Natural History Museum, it is the image of a prehistoric woman.

Over all the cultures, the representation of the female body has been significantly larger in size than its male counterpart. In Paleolithic representations, female characteristics are unmistakable: adiposity of the torso, large buttocks and huge breasts, all of which underline the role of fertility and nutrition as a symbol of elevated social status.

It is unknown, however, whether the archeological Venuses are faithful representations tailored to the reality of what was observed or are an artistic and idealized vision that symbolizes the desire for abundance and fertility, particularly in a period of the history of humankind when hunger was a threat to human life.

Ford and Beach [13] studied 190 tribal societies and, as was observed in the Paleolithic figures, found in virtually all of them that obese women were considered more beautiful than their thinner counterparts owing to their greater procreative and feeding capacity. On the other hand, men’s attractiveness lay rather in their skills and social standing.

Prehistoric sculpture representing the female prototype usually symbolizes female fecundity together with birth-giving and breastfeeding capacity. This was also contained in myths such as Hera’s drop of milk, which gave rise to the Milky Way while she was suckling Hercules.

A large woman’s body symbolized prosperity and luxury. It even suggested an abundant harvest. Both of these were necessary for group survival. Thinness signified sterility and penury. At a time of frequent famines, thinness was considered to be a messenger of death [14]. This evaluation of the physical attributes of females has never occurred in the animal kingdom, where the males possessing greater size and brighter colors (as well as other characteristics) conduct courtship.

In Classical Greece, the attractiveness of the male body took precedence over that of the female. The cult of the male form, including being in good physical condition within the broader context of understanding the body–mind duality in this culture, represents a very different viewpoint from the subsequent concepts defended by Christianity [8].

In Ancient Greek, the word limos means “hunger.” On adding the word bou, which means “a large amount,” or boul, which means “ox,” the resulting term may be translated as “voracious hunger” or “ravenous hunger.”

In 970 B.C., Xenophon, in the Anabasis, described for the first time in Western culture what we now see as bulimic practices. This referred to the eating habits of some Greek soldiers who withdrew to the mountains of Asia Minor after mounting a campaign against Artaxerxes. It is interesting to note that these soldiers received only scant food rations [15]. Hippocrates distinguished boulimos, unhealthy hunger, from ordinary hunger. Aristophanes also used the same term in its meaning of “ravenous hunger.”

For the Greeks, the measurement of beauty was the aureal proportion, a practical application of their cult of balance. Hippocrates defines in his work the functioning of the body according to physical elements and bodily humors. Health was synonymous with a state where there is proper balance between the humors, while illness appeared as an imbalance in the interaction between them. The female body is considered weaker and more prone to illness.

In the history of psychiatry, the pathological condition of the female body is a constant. For Greeks, hysteria is a word that means “uterus.” Plato [56] in his text Timaeus (which has entered Western medical tradition through Galen and the Hippocratic writers) asserted that:

… the matrix or womb in women, which is a living creature within them which longs to bear children. And if it is left unfertilized long beyond the normal time, it causes extreme unrest, strays about the body, blocks the channels of the breath and causes in consequences acute distress and disorders of all kinds. If it is not ‘appeased by passion and love’ the womb moved from its natural position within the body and, attaching itself to soft internal tissues, gave rise to a wide variety of symptomatic disturbances. (Plato 2005, p. 123)

Hippocrates identified the relevance for health of such factors as dietary restraint, an increase in exercise and a reduction in sleep. Hippocrates was the first to indicate the risk to health of obesity, which he associated with the existence of menstrual changes and infertility in women. He explained that infertility is a consequence of the fat accumulated in obese people, hindering intercourse, and closing the mouth of the womb. Hippocrates saw the therapeutic rules for combating obesity as: having a tough job, sleeping in a hard bed, eating only once a day and preferably food with a high fat content (in order to be satiated quickly), and walking naked as much as possible. More specifically, food needed to be taken soon after a hard day’s work when the body was still tired and one had difficulty breathing.

Ancient Rome disagreed with Classical Greece in most of its body esthetic criteria. The Romans were more interested in the peculiarities of faces and people [8]. However, they produced a culture that valued thinness or at least tended to avoid excess weight. As they enjoyed copious banquets, they used vomiting as a means of regulating weight. Both bingeing and vomiting were socially accepted and therefore were integrated into their culture, especially in the middle and upper classes. Roman banquets could include over 20 courses. Whenever the stomach of the diners was full, they went to an adjoining room, the vomitorium, where vomiting enabled them to recommence their blow-out. In his treatise on morality, Dialogi, Seneca writes in De consolatione ad Helvia about Roman practices: “Vomunt ut edant, edunt ut vomant” (they vomit to eat and they eat to vomit).

Moreover, a woman was appreciated fundamentally for her role as mother in which she was obliged to present many children to a State that needed them to ensure its survival against the continuous threat of the intrigues of its enemies [16]. In return, this led some women to rebel against their fate, as was denounced in the writings of the philosopher Favorinus: “Not only do they refuse to breastfeed their children but they resort to a thousand tricks to avoid becoming mothers.” Metrodora, a female physician of Greek origin who practiced in the Rome of the first century, wrote a treatise on female illnesses. In her chapter devoted to young women, she described sitergia, a Greek term whose literal meaning was “rejection of food.”

Medieval cooking stems from a reaction to the banquets and abuse of wine that characterized the final days of the Roman Empire. Just like the Egyptian hermits and anchorites who barely ate enough to stay alive, the early Christians and some mystics interpreted food restraint from the religious viewpoint and practiced fasting as a penance (intensification of prayer, rejection of the world), and as a means of reaching the highest, purest spiritual state. “An emaciated body will pass more easily through the narrow gate of paradise; a light body will resurrect more quickly and a consumed body will be better preserved in the tomb” (Tertullian). Religious asceticism constituted a means of being above bodily needs and reaching a “pure” spiritual state.

In the Middle Ages, the reproductive woman and her figure were the predominant value on the esthetic scale. The female body had to denote corpulence, with a rounded belly as the symbol of fertility. It is significant that the ruling aristocracy were then generically called popolo grasso, (plump people), while the working classes are recognized as popolo magro (thin people) [10].

The appreciation of fatness implied the rejection of thinness, that is, a flight from hunger, illness, and poverty. The body and its functions were not hidden; everything was natural. It was possible even to defecate or have sexual intercourse in public without creating a scandal or a commotion [17].

For its part, Christian doctrine viewed the body as weak and sinful, requiring strict control and regulation by the mind. Ascesis was the path that led to perfection. Flesh needed to be overcome; the spirit had to triumph. Fasting was the ideal way to achieve this. Religious demands existed so that women would detest their bodies. The less their flesh was consented to, the holier they were. In this way, many women from comfortable classes left their homes and families for a religious life rather than marriage, the only way out for a woman; the convent also offered them the chance to receive an education which otherwise would have been impossible. We should remember that these were patriarchal societies where women were second-class citizens. (At the Council of Trent in 1563, the Inquisition established guidelines to be followed by women whose bodies did not belong to them. If they were virgins, they belonged to God who could call on them and, if not, they belonged to their husbands. If they were possessed, they belonged to the Devil and were persecuted and tortured; at prior Councils such as Nicea, it was discussed whether women had souls.)

Indeed, fasting was a symbol of medieval ascesis. But while monks fasted to purify their bodies and strengthen themselves before the temptations of the outside world, women sought the liberation of their own bodies, which were considered in Christian thought to be the true origin of sin. We should not forget that Christianity blamed original sin on Eve; she was the one to offer the apple to Adam, whose weakness was to accept it. Eve’s original sin was in herself while for Adam sin was positioned in the outside world. It was in this context where “holy anorexia” (anorexia suffered by following God), appears, as noted by Rudolph Bell, a history professor at the University of Rutgers [18]. Bell reviewed the biographies of over 261 Italian nuns from the thirteenth century to the present day and found that many may have suffered anorexia nervosa. One was St. Liberata (St. Wilgefortis, a name that comes from Latin and means “strong virgin”). She challenged her father, the King of Portugal, by refusing to eat when he arranged her marriage. Asking God to take away her beauty, her body became hairy (lanugo, owing to malnutrition) and she even grew a beard. Her father decided to have her crucified rather than allowing her to enter a convent. Another example was St. Catherine of Siena. When she was 26, her idea of devoting her life to God clashed with her father’s plan to marry her off. This situation led her to lock herself in her bedroom and refuse to eat. In the end, she entered the Dominicans’ order, although she had lost half her body weight. Her head may be found in the church of Saint Domingo in Siena as a relic exhibited behind a glass urn; the rest of her body is buried in Rome and one of her feet is in Venice, as an example of holiness. She said in her final writings that she believed she was ill.

In the Renaissance, and principally in the various European courts, the body and overall appearance was granted a significance that was unknown in medieval Europe. In the court, food was usually guaranteed and habituation to it enabled it to be savored. Physical strength and the battle gave way to personal intrigues. The maintaining or improving of social status did not depend as much on fertility or body frame as on the social importance attributed to an individual, this being down to bearing, speech, manners and appearance [19]. The body became socialized.

From the fourteenth and fifteenth centuries, anorexia began to spread from the convents and the abbeys like an epidemic. This phase, called “secularization of anorexia,” continued into the sixteenth and seventeenth centuries. The miraculous maidens appeared, most of them youngsters of humble origins who, by refusing food, attempted to attain the sublime, perfection and purity and, in the process, improve their social and economic standing.

Anorexia was progressively stripped of its religious background and moved to a more vulgar circle, with the appearance of so-called artists of hunger, who would exhibit at fairs and could even be seen in some cafés. Kafka described one of them in his story An Artist of Hunger.” As Paul Auster asserted in his essay The Art of Hunger [20], these new, secularized anorexics did not fast in the same way or for the same reasons as the mystics of the past. Their rejection of food was not an attempt to reject earthly life in order to gain entry to heaven. It was simply a refusal to live of the life into which they had been born. The more prolonged their fasting, the greater the space that death occupied in their lives. Their fasting was a contradiction: to go on with it meant death, but death also ended fasting. Therefore, they needed to stay alive, but only to remain on the edge of the abyss, as reflected in the novel Hunger by the Nobel Prize winner, Knut Hamsun.

From the fifteenth to the eighteenth centuries, the large woman remained the model, however. This woman, even when obese, was considered to be attractive and elegant [8], like the fleshy women portrayed by the Italian Renaissance painter, Titian.

The history of the western world, and that of Europe in particular, is littered with characters, eras, and social groups in which bingeing and then vomiting was practiced assiduously. These vomiting individuals included England’s Henry VIII and his closest subjects; Pope Alexander Borgia and his courtiers; Bruegel’s playful Flemish peasants and Bosch’s lacerating throngs; and, much more recently, Britain’s King Edward VII of the UK or US President William Taft (all of them men) [21].

According to the Encyclopaedia Britannica of 1797, bulimia is defined as a disease in which the person is affected by a desire to eat insatiably and perpetually, and unless this is satisfied, it leads to fainting. Motherby, in 1785, had already described three types of bulimia: that characteristic of pure hunger; that where hunger ends in vomiting; and that associated with fainting.

We find the most complete reference to this disorder in James, who in 1743 devoted two pages to describing boulimos [6]. He noticed that while some patients experience the complication of vomiting after ingesting large amounts of food, others do not. He distinguished in this way between boulimus and caninus apetitus. Basing his approaches on Galen, he remarked that boulimus was caused by an acidic humor contained in the stomach, which produced intense but misleading indications of hunger.

At around the same time, the word “anorexia” was used in medical literature as a synonym for lack of appetite. The first medical approximation to the disorder came in 1689 from Richard Morton, the court physician of William II. In his work Phthisiologia, seu Exercitationes de phthisi, which is translated into English and subtitled A Treatise of Consumptions, he described a condition of anorexia nervosa with great accuracy. He related the condition of an adolescent boy of 16 and that of a young woman 18, of whom he said: “…I cannot recall in all my life anyone who was so involved with living and so consumed…” [22].

Subsequently, in 1764, Whytt described “nervous atrophy,” based on the case of a boy of 14 who, after a period of loss of appetite and weight loss, went through a phase of impulsive ingestion, the symptoms not being attributable to any known pathology. In describing the case, Whytt referred for the first time to bradycardia as a symptom associated with cachexia.

In 1798 in France, Pinel published his Nosographie Philosophique [23] where he included anorexia, bulimia and pica in the chapter on digestive neuroses. The writer considered anorexia to be a frequently-presented gastric neurosis.

Many of our sociocultural values appeared to develop and become consolidated in this period, including the origin of slimming culture. Among them were: the existence of a growing bourgeoisie, the development of urban centers, the industrial revolution, and, subsequently, the development of the media [11].

In 1840, Imbert’s Traité Théorique et Pratique des Maladies de Femmes was published. He included anorexia, bulimia and pica as stomach neuroses and distinguished gastric anorexia from anorexia nervosa, attributing the former to a digestive disorder of gastric origin and the latter to brain alterations. He also remarked on how patients with anorexia nervosa showed a loss of appetite and a great variety of neurotic signs, becoming melancholy, choleric, and fearful.

Two decades later, Marcé (1860), a physician from the University of Paris, described a form of hypochondriacal delirium that was consecutive to dyspepsia and was characterized by rejection of food. Patients, either because of a loss of appetite or discomfort caused by digestion, reach the crazed conclusion that they could not or must not eat.

It was in the midst of the Victorian Age when the contributions by William Gull and Ernest-Charles Lasègue appeared. These two authors began the scientific study of anorexia nervosa. Gull, Queen Victoria’s physician, described “hysterical apepsia” in London in 1868. He said that this was a typical condition of young women that led to emaciation and that was initially felt to be of organic origin [24, 25].

Soon afterward in Paris, in 1873, Lasègue published the manuscript De la Anorèxie Hysterique where he described the cases of various patients aged between 18 and 22. He emphasized the emotional etiology of the disease, presenting it as a perversion or intellectual anomaly and indicating at its heart perturbed interpersonal relationships and, on occasion, unconscious desires as the basic personality traits of such patients [26].

In his description, Lasègue added something that we feel is important, bearing in mind subsequent interpretations of the anorexic syndrome: “fasting is not total and is completely unconnected with the rejection of foods practiced by the melancholy.” As well as underlining emotional alterations resulting from the transition to an adult age in the etiology of the anorexic syndrome, he also indicated the existence of social aspects for the first time. He is probably the first doctor to consider the possibility of inter-family conflict between anorexic patients and their parents [27].

Six months later, Gull (in 1874) used the term “anorexia nervosa” for the first time. This was in an article in which he described the findings derived from the malnutrition of three anorexic patients, without paying attention to emotional aspects. This new name for the disease came about for two reasons: the rejection of the term “apepsia” as no alterations in digestion of food were observed and the rejection of the term “hysteria” on specifying that these patients did not present the clinical history of the typical hysteric. It recognized, however, the role of different psychological aspects that may well intervene in the etiopathogeny of the anorexic condition.

Gender perspective cannot be ignored in the genesis and maintaining of the eating behavioral disorders suffered mainly by women. Men and women have different ways of living in their bodies. At that time in history, women lacked the right to vote, they had no access to university, and they did not even have access to the inheritance of their parents unless they formed a good marriage. Hence, anorexia nervosa may be understood to be a challenge to the established order. It questions health criteria and questions the symptoms as social by incarnating a body exposed to the gaze. The appearance of the disease as a clinical diagnosis occurred at the same time as the appearance of novels written by women, such as Wuthering Heights (initially published under a male pseudonym as this was the only way to get published) by Emily Brontë (who was suspected to suffer from anorexia nervosa), and including the work of Jane Austen. All the female characters in literature up to that time had only been seen from the viewpoint of their relationship with the opposite sex. “And this is such a small part of the life of a woman” (as Virginia Woolf said). Love was the only role possible for women. Woolf [28] wrote that if in Shakespeare’s tragedies men had been presented only as lovers of women and never as friends of men, as thinkers, as dreamers: “What few roles they could play! How literature would suffer!” This is how women have suffered in history, with the symptomatic expression of inequality and social unfairness frequently being anorexic symptoms. Many women allow themselves to be locked in the “prison of the body” represented by anorexia nervosa. “Hunger, insomnia, disease” were the three words Oscar Wilde used to describe his time in Reading prison in letters to friends and relatives. The problems of prison are also problems of the body and, in this case, prison became the body for these women.

The prestigious French physician Charcot, known for his study of hysteria at La Salpêtrière Hospital in 1889, proposed parentectomy (the isolation of the patient from her/his family) as a therapeutic formula for patients with anorexia nervosa. He was the first to indicate “fear of obesity” as a reason for refusing to eat.

Meanwhile, Lord Byron was the prototype of the romantic writer whose fame and literary prestige helped to publicize his ideas on the body and the mind. He fasted to clear his mind; he defined himself as “ascetic vegetable eater.” He abhorred fatness as in his view it symbolized lethargy, clumsiness, and stupidity. His food restraint was accompanied by physical exercise: “I don’t find it at all hard to fast for 48 h. Two years ago, I lived permanently on a diet of a thin slice of bread for breakfast, a dinner of fresh vegetables, only green tea and carbonated water in the interim. These days, when I start thinking that I am consuming, I chew tobacco, mastic gum or laudanum…” [29].

The first description of a diet was published in 1863. In it, a layman explained the way to reduce food ingestion with the aim of losing weight. This appeared in all the books that referred to food over subsequent years.

The image of women historically perceived and conceived in terms of their reproductive function started to show a clear change with the development of science. At this time, talk began of combating obesity by reducing food ingestion and increasing physical exercise. In fact, this was a return to Hippocratic advice.

In 1875, the concept of energy balance was described and it was postulated that a greater intake of the foods the body needed led to an excess of weight. Greed or gluttony emerged as the principal cause of obesity. It was also in this period that two causes of obesity were described. On the one hand, there was talk of obesity caused by a physical problem (with symptoms similar to Prader–Willi syndrome), and on the other, obesity due to hyperphagia secondary to a defect in the person’s character (with symptoms resembling Pickwick syndrome).

It may be asserted that it was really in the nineteenth century that the first progress in the study of obesity was made, with an important role played by writers who worked almost simultaneously in Edinburgh, Paris, and, subsequently, Germany. In fact, the interest in obesity in the latter country gave rise to numerous physiological theories, some of which are discussed even today [30]. These include body composition, energy conservation, the excess of fat cells as a cause of obesity and the concept of family obesity. In late nineteenth century Belgium, Quetelet developed the Index that bears his name and that relates a person’s weight in kilograms to the square of their height in meters. Subsequently, following the introduction of the Lavoisier calorimeter, it was suspected that obesity could well be a metabolic disorder.

In the twentieth century, a true explosion occurred and anorexia nervosa and bulimia nervosa increased to almost epidemic proportions. Specific intervention programs were created for these pathologies and there were major advances in research into obesity. Why was there such a large increase in the number of cases?

Psychopathology, as Jules Henry said, “is the final outcome of all that is wrong with a culture” [31]. Nowhere is this more strikingly true than in anorexia and bulimia, which were barely known two centuries ago, but which have reached epidemic proportions in the twentieth century. Far from being the result of a superficial fashion phenomenon, these disorders reflect our attention to some of the central ills of our culture, from our historical heritage of disdain for the body, to our modern fear of loss of control over our future, to the disquieting meaning of contemporary beauty ideals in an era of greater female presence and power than ever before” [32].

Changes in the incidence of anorexia have been dramatic. In 1945, when Ludwig Binswanger chronicled the now famous case of Ellen West, he said, “from a psychiatric point of view, we are dealing here with something new, with a new symptom” [33].

Anorexia nervosa is clearly, as Paul Garfinkel and David Garner have described it, a multidimensional disorder. It has familial, perceptual, cognitive, and biological factors that interact in varying combinations in different individuals to produce a final common pathway [34].

Bray [35] cited the principal areas connected with scientific developments over the century: the study of food intake and its control, and the use of behavioral measures for losing weight.

Habermas [36], who studied the historic concept of the voracious appetite (Heisshunger), saw bulimia nervosa as a much more recent disorder than anorexia nervosa and placed its origin at the start of the twentieth century. He also believed that pressure and the struggle of doctors against obesity originated in this phenomenon.

The contraceptive pill revolution allowed women to separate sex from procreation, as women on the pill could control their fertility. However, although it was acceptable for single men to have sex, when women showed the same attitude it proved disturbing for 1950s Western society. At that time, contrasting with the middle-class women who were once again out of the factories and safely immured at home, the dominant ideal of female beauty was exemplified by Marilyn Monroe. She was often described as femininity incarnate, femaleness embodied.