Anais Garcia, 21, anxiously stares at the menu of a Bob Evans restaurant in Baltimore. Her dark brown eyes gravitate toward the Fit and Healthy section, which lists calories per meal. She takes a long time figuring out what to order and decides to go with her "safe meal," a small stack of pancakes, with no butter, reduced-calorie syrup, a small bowl of fruit on the side and a cup of black coffee.
"Restaurants are like battle zones for me, literal war zones," she says.
A ballerina who contended with anorexia nervosa for years, Garcia, who is just over five feet tall, has reached 105 pounds, a safer weight than the 79 pounds of a year ago. In her gray turtleneck sweater and casual black leggings, her extreme thinness remains apparent. "For the past five years, I've done nothing but hate and try to disown my body," she says.
Ballet celebrates the body - and thinness. Despite demands for change from dancers who have experienced problems and from psychologists specializing in eating disorders, the stereotype that a dancer must be elegant and lean persists. Ballerinas become vulnerable to self-consciousness about their bodies, and they face increased risk of anorexia, bulimia nervosa and other eating disorders.
Generally, someone who develops an eating disorder has a predisposition, with several factors at play. For ballerinas, "it is of course the ballet culture," which is competitive and demanding, says Linda Hamilton, a New York psychologist who has worked with ballerinas with eating disorders. But "you might also have a personality predisposition," she says. "A perfectionist personality can make the dancer intolerant of any physical changes."
Sometimes, "the disorders start early, as young as 12," she says, because the curves that come with puberty don't fit the ballet look.
"One out of two dancers suffer from an eating disorder," Hamilton says. "It's still an ongoing problem and it needs to be addressed, because once ballerinas develop an eating disorder, it's hard to recover."
Born in Columbia , Maryland, Garcia was brought up by her mother after her parents divorced and started dancing when she was 3. By middle school, intent on pursuing a professional ballet career, she was dancing four to eight hours a day. "It just became an obsession," she says.
She became a professional at 19. She danced for two years across the United States, performing in Miami, in Washington for the Washington Ballet and in New York for Dance Theatre of Harlem.
"It got really serious very fast," Garcia says.
No one in her family ever ridiculed her for her size, she says, attributing her eating disorder to the competitive nature of ballet itself.
At 13, living in Baltimore, she was determined to enter the Baltimore School for the Arts (BSA), a respected public high school with an outstanding reputation in ballet. She was rejected, she says, not because of her dancing but because the faculty decided she needed more muscle tone.
"I remember that when she didn't get in, it was her mother who contacted me and we spoke about her weak muscle tone," says Norma Pera, the dance department head. "We are looking for a body that is physically fit enough to aerobically do the work."
Garcia auditioned again and was admitted at 14, as a sophomore. Teachers, she said, repeatedly said she was "too soft" and encouraged her to have more "muscle tone" - terms she took as code for "fat."
Pera says that at BSA, "we never tell a student that they're fat ... that would be a very destructive and horrible thing to say." She says she doesn't make comments that imply a student should look skinnier. "The student hears what they want to hear," she says.
Garcia started school at a normal and healthy weight, about 115 pounds. By the end of her sophomore year, she had lost 15 pounds, and in the high-pressure environment, her weight kept dropping. "I slowly slipped into a dangerous spiral of wanting to please my teachers," Garcia says.
Garcia is convinced her lower weight produced results.
When she won the lead role of Clara in "The Nutcracker," in her senior year of high school, she felt that reinforced the idea that "being skinnier was better." She began using laxatives, purging, skipping meals and overexercising, to lose still more weight.
"For some reason at that stage, I broke down," she says. "At the very end, when I was doing my bow."
She understood she was ill and "that my sickness was only going to get worse and that anorexia had taken everything that once made me happy, and just made it a living hell," she says.
But her desire to become a professional was more powerful than her sickness.
Pera says that she and the other teachers had no indication that Garcia was going through a severe eating disorder.
"I thought she was quite happy at Baltimore School for the Arts," Pera says. "I am sorry that she feels she had to lose weight to get a role, but that's not true."
In the early 1990s, Hamilton and Michelle Warren, a professor of obstetrics and gynecology at Columbia University and an expert on eating disorders, spent three years surveying dancers at the School of American Ballet, affiliated with the New York City Ballet, to see which dancers developed eating disorders.
They noticed that most students denied having an eating disorder, even when they showed symptoms of anorexia or bulimia nervosa. The researchers canceled their survey after 70 percent of the dancers dropped out of the study because they started to encounter trouble with the school.
More than 20 years later, ballerinas remain exposed to the same problems.
Most ballet schools have incorporated nutritionists and other programs to help dancers stay healthy, but "often you get mixed messages," Hamilton says. The companies and schools may talk about health, "then you see that the skinniest dancers are the ones who are getting cast" in lead roles.
To address eating disorders in ballet, Hamilton says, "the whole environment has to support that," including teachers and choreographers at ballet schools. They have to educate dancers, to prevent them from developing dysfunctional eating habits or relapsing after treatment.
Garcia had graduated from BSA in spring 2015. She decided to start company auditions a year later, after dropping out from her first semester at Towson University in Baltimore, where she was majoring in dance performance.
"Pursuing companies full time meant I had to watch what I was eating," she says, calling it probably the worst decision she had made because "I was eating a granola bar and a coffee per day."
Garcia checked into the Renfrew Center of Philadelphia in August 2017 for treatment of her eating disorder, a decision that followed what she calls the "hell semester."
She remembers a cold morning in March that year, when she decided to have photos shot to include in her portfolio for dance company applications. She was wearing a thin, red dress with no jacket.
"My body was so thin and weak," Garcia says. "I just wanted to die. I was so weak, I couldn't move. I was ready to peacefully go."
But her mother called the paramedics, who arrived when she was passed out on the sofa. After checking her vitals, they determined that her pulse was very low and that she had just suffered from a panic attack. "I look at those photos now, and it's devastating and scary."
Garcia's final audition came later that month. She had an opportunity to audition with Dance Theatre of Harlem in New York.
"I told my mom, 'I have to go, this will be it!' " But as she was going upstairs to put on her black leotard and ballet shoes, she recognized for the first time, as two psychiatrists had previously suggested, that she had body dysmorphia - a body image disorder that causes people to constantly worry about their appearance and to obsess over their looks.
She realized how weak she had become.
"I pushed through everything, but this was bad, because I admitted it," she says. On her way home from New York, she recalls grasping that her illness had worsened. "I never went to another audition."
Garcia entered the intensive inpatient program at Renfrew after enduring serious depression for months. Her heartbeat was a very low 35 beats per minute. "They said it was bad. My heart was literally stopping," she says. But the doctors fed her and plied her with Gatorade. Within a week, her heartbeat had risen to a normal 75 beats per minute.
During the three-week program, doctors diagnosed her with anorexia, anxiety, depression and post-traumatic stress disorder.
After she completed the inpatient and partial hospitalization program at Renfrew, she transferred to its intensive outpatient program, which allowed her to move home to Baltimore, checking in with therapists and nutritionists three times a week.
According to Renfrew's staff, Garcia's ideal weight is 115 pounds.
Eventually she transferred to the Renfrew Center in Baltimore, where she attends a mandatory Monday support group with her mother and boyfriend.
On a recent Monday, she and 13 other patients suffering from anorexia, bulimia or binge eating are sitting in a spacious, bright conference room at Renfrew, waiting for family members or loved ones to arrive.
Here, patients can talk about the difficulties and challenges of their disorders with people who share the problem. A therapist leads the conversation.
When the meeting begins, the family members and loved ones introduce themselves and say whom they've come to support. "Hi, my name is Wanda, and I am here to support Anais," says Garcia's mother. Anais, who has looked depressed, breaks into a smile, proud that her mother is still by her side. Her boyfriend then says the same thing.
Many of the patients look extremely sick, thin and anxious. A young woman in the front of the room, who won't even look at her parents, constantly bites her nails. But Garcia holds her mother's hand.
The therapist passes around handouts to spur patients' discussion on how a loved one has cared for them through their disorders.
"Take a couple of minutes to decide which term best identifies your relationship with the patient," the therapist instructs.
"Mom, I think this is you," Garcia says after some debate. She points to "The Kangaroo," the type of person who does everything to protect the patient, often taking over all aspects of his or her life. But Wanda says she identifies more with "The Dolphin," who "is helping someone with an eating disorder by gently nudging them along."
After an hour, the discussion ends and the Garcias head home. It's one of Anais's last meetings, before she finally can say she has recovered.
Garcia no longer pursues a professional career in ballet, but she is dancing as a hobby. "I'm going into the studio by myself and put on some music and just dance," she says. "I did it for so long in my life that I miss it."
She is on a new career path, majoring in exercise science at Towson. She plans to go into a physical therapy school afterward.