A slow suicide

How women in Russia abuse medicine to lose weight

In April 2017, Meduza published a story about the life of Russians suffering from eating disorders and body dysmorphic disorder (BDD). There aren’t reliable statistics measuring the number of these people in Russia, but even the most conservative estimates put their population at more than 10,000. One of the most important aspects in this problem is the abuse of medicine. Diuretics and antidepressants weren’t developed to cause weight loss, but many young women (the most common victims of eating disorders) are turning to these drugs for precisely this reason, leading to serious health risks. In a special report for Meduza, Maina Vasilieva, a journalist from the website Delovoi Peterburg, looks at how girls in Russia with eating disorders are abusing drugs and faking prescriptions.

The names of some of the women in this story have been changed at their request.

Natalya says she’s considered herself unattractive since childhood, when she first started discussing weight issues with her classroom friends. In high school, she decided to lose weight. She dieted for several months, skipping desserts and dinners, without using any drugs. “Then I realized that the calories don’t stay, if you vomit,” she says. “After that, I began to take pills: laxatives, antidepressants, and appetite suppressants.”

When Natalya was doing this in the early 2000s, she had to guess what medications would work best. Today, women in her position don't have to guess, thanks to social media and its myriad groups dedicated to sharing weight-loss tips. On Vkontakte, these groups have names like “Typical Anorexic,” “Skinny,” and “Zero Calories.” Maria, who lives in Moscow, joined several of these groups after a rough break-up. “He told me I’m fat,” she says. “This added to my depression. I stopped eating. I got obsessed with glossy magazine covers. Then I joined these groups, and that's when it all started.” To lose weight, she took furosemide — a powerful diuretic with short-term effects. The side-effects, however, include arrhythmia, general fatigue, fever, headaches, and stomach aches. Overdoses can even cause heart failure. Maria took furosemide for several months. Today, five years after quitting the drug, she still has kidney problems.

Yulia from Kharkov had a crush on a basketball player and, as she puts it, “didn't want to look like a roly-poly beside him.” She also took diuretics, then moved onto antidepressants. “You go to the bathroom eight times every night. They really drain your body and burst the blood vessels around the eyes,” she told Meduza. “The second night, on another bathroom dash, I fainted right in the middle of my dormitory hallway.” Yulia tried other ways to lose weight, too. She took what’s called “the ECA”: a combination of ephedrine, caffeine, and aspirin. “One dose and you feel high. Your heartbeat goes up, and you start sweating profusely,” she says. And there was also a laxative called Bisacodyl. “That was the worst,” Yulia recalls. “You eat an apple, swallow five bisac (short for Bisacodyl tablets), and you’re basically chained to the bathroom for the whole night, until there’s not a drop left in you.” These drug experiments caused Yulia to lose ten kilograms (more than 22 pounds), but she also became withdrawn and developed a fear of the subway, where it seemed to her that “everyone was staring.” She started fainting, too — sometimes in the shower and sometimes while riding public transportation.

Describing her efforts to lose weight, Natalya said, “It was a kind of suicide for me, only a slow one. It was like going about my daily business while falling out of a window at the same time.”

Diuretics to sharpen the features

Until the mid-20th century, doctors rarely diagnosed eating disorders (the best known being nervous anorexia and bulimia). A rise in the number of recorded cases is usually associated with the spread of glossy magazine culture and new beauty standards. According to research by the psychiatrist Hans Hoek, four in every 1 million people were diagnosed with eating disorders in the 1950s. Just a decade later, cases were four times more common.

There’s no precise data about how widespread eating disorders are in Russia. Hardly any of the young women who spoke to Meduza for this story had also talked to a doctor or even their friends and relatives about their condition. In 2006, the researchers Valery Romatsky and Igor Syomin wrote that the number of people in Russia who suffer from the most common eating disorders (anorexia and bulimia) may number between eight and 12 cases per 100,000 people, but these averages are based on information available in Europe and the United States. Both Meduza’s sources who work with eating disorders in Russia and the many weight-loss communities on social media suggest that the problem could affect as many as hundreds of thousands of people.

There are online groups in Russia where people with eating disorders motivate each other to lose weight. On the social network Vkontakte, there are dozens of communities called “Typical Anorexic,” the largest of which has more than 863,000 followers. Searching the website for “anorexia” turns up another 700 or so groups — ten times fewer than in April 2017, when Meduza last published a report about eating disorders in Russia. Vkontakte confirms that it deletes any user or community responsible for “radical incitements to harm people’s health,” if users complain. The company also points out that groups can close down for other reasons, and inactive communities disappear from Vkontakte’s search results.

Taking drugs — typically medications that weren’t developed to induce weight loss — is one of the most popular recommendations in online anorexia-communities. Staff at nonprofit organizations in St. Petersburg who work with eating-disorder patients estimate that there have been hundreds of thousands of cases over the past decade of younger and older women abusing medication to lose weight.

One of these drugs is furosemide, a strong, fast-acting diuretic that can be purchased in drugstores for as little as 13 rubles ($.23) a pack. “People with eating disorders often take it to expedite the elimination of water or to sharpen their facial features,” says Yuilia Sibagatullina, a doctor at the “Enso-Terapia” medical center. Physicians usually prescribe Furosemide to patients with high arterial pressure or those suffering from severe edema of the brain or lungs. The drug actively removes potassium and liquid from the body, which is why hospital staff keep patients receiving this treatment under constant observation, with particular attention to their blood pressure and pulse. As Sibagatullina explains, uncontrolled and unprescribed use of furosemide may lead to a sharp drop in blood pressure and fainting, while the decrease in potassium can cause arrhythmia.

Laxatives used to lose weight, like Bisacodyl and senna extract, can also cause health problems. According to Victor Levi, the chief physician at the Israeli clinic “Levisrael,” laxatives remove electrolytes and liquids needed in the body, leading to arrhythmia, cramps, and confusion.

Another popular drug is Fluoxetine. Usually prescribed to those suffering from depression, it can cause anxiety and overexcitement. According to Levi, a person in this state is “susceptible to a lack of good judgment, which is often life-threatening for the persons themselves and those around them.” Sibigatullina adds that patients who take antidepressants often recover their physical strength before their emotions. This can lead to suicide attempts, and constant monitoring is therefore necessary.

Sibigatullina points out, however, that some individuals aware of the side-effects still decide to abuse different drugs to lose weight. “They think, well, I’ll just be careful and I’ll be fine,” she says. Natalya from St. Petersburg admits that her case was very similar. “When I told my therapist that I’d been taking different drugs without any prescriptions, she asked me if I’d do that now,” she told Meduza. “I said I’d consult her first, but I thought to myself, ‘Hell no. I’d do the exact same thing.’”

Disturbing hallucinations

“Once, I vomited food that I’d eaten a day ago, and it looked almost the same — like it was all just stored inside me for two days,” says Natalya. “Then I choked, put my fingers in my mouth, and pulled out a handful of laxative tablets — also perfectly undigested, still round and yellow. These things scare you at first, but then they begin to seem normal.”

“We all have moments when we lose our self-control. Like when you fight with your husband or yell at your kids. And you understand in part that you’re wrong, and you can even see yourself doing it, but you can’t stop,” Natalya says, trying to explain the logic that guides someone with an eating disorder. “When my bulimia is acting up, I start feeling nervous and anxious. Then, without doing anything, I realize that I’ve already lost. And I know that on my way home I’ll go buy two chocolate bars, a few packs of cookies, eat them all, and then stick two fingers down my throat and throw up. Or I’ll take a whole pack of Bisacodyl.”

Meduza spoke to other women who shared similar stories. Throughout her childhood, Olga from the town of Electrostal was teased and called “fat.” When she read a book about models, she realized that she wanted to become “part of that world.” Then, among her sister’s subscriptions on Vkontakte, she found an online community about anorexia. “I began by making this potion (ECA) using the recipes made up of drugs available in drugstores and supermarkets. Soon this wasn’t enough, and I started ordering ephedrine [from members of this online community],” she says. “I developed a pretty strong dependency, took a lot of the drug, and wouldn’t eat for weeks. I ended up in a psych ward. I suffered from bad withdrawal. I thought my bones were turning inside out. I sat in a corner, and curled up into a ball.”

Anastasia from Ufa was introduced to the drugs by her friend, who found out about them from an online community. The girl had already tried to lose weight though diets and forced vomiting. She decided to try Fluoxetine and Grandaxin (a tranquilizer used to reduce anxiety) after she read some comments about how they help lose weight; she got the drugs from her older sister, who never asked what she wanted them for. “I was so hungry that I wanted to kill everyone,” Anastasia says. “Everything made me annoyed and angry, and the tablets made me calm down. I started to sleep more — around 9-10 hours — but I was still tired. With the medication, I stopped eating altogether. I just drank water — sometimes tea with honey. So my mom didn’t notice that I wasn’t eating, I ate everything she made, and then it was two fingers down my throat.”

Polina from Tyumen also tried losing weight by dieting. At 13, she discovered the anorexia communities. “I think many of us start using medication out of frustration with failed attempts to lose weight. You start looking for that ‘magic pill’ with easy and lasting results.” Polina took nicotine acid (a vitamin that influences your metabolism), and microcrystalline cellulose (which is used to fill the stomach and suppress hunger). She’d move on to tranquilizers, laxatives, and diuretics. The popular Russian drug Phenazepam gave her energy and suppressed her emotions. “I had a weird way of entertaining myself. I would take a large dose, experience incredible hallucinations, and then I’d fall asleep so quickly I didn’t even make it to bed.” Fluoxine made her feel apathetic, while other drugs brought on dehydration and nausea. According to Polina, however, the drugs nonetheless gave her a sense of calm. Motivational posts and positive reviews in online communities strengthened her belief that everything would be okay. Now 17, Polina is in therapy and still finds it hard to eat regularly. She says her antidepressants no longer have much effect, and she’s been diagnosed with chronic gastritis.

Inga from St. Petersburg told Meduza that she started taking drugs because of a “very week reflex.” “I can’t throw up,” she explains. “I tried everything: sticking two fingers in my mouth, a spoon, salt water, water with manganese — and nothing. So I chose laxatives.” She also started taking Broncholitine (an ephedrine-based cough syrup) and several kinds of antidepressants. “When the bulimia began, I was ashamed to tell anyone. I kept losing control,” Inga says. “I would raid the fridge and eat everything. I could eat a kilo of marshmallows or cookies, wash it down with a liter if milk, and then I'd take the tablets and moan from stomach pains all night long. It was very painful, my stomach was overfull and in pain, and it was hard to breathe. And the pills made it even worse. The effect of laxatives is very painful, as if your intestines tie themselves into knots.” Today, having overcome her bulimia, Inga still suffers from insomnia.

Polina Bashurova, another young woman living in St. Petersburg, says there are lots of options, but Fluoxetine and Bisacodyl are the standard drugs selected by girls with eating disorders. “Fluoxetine can give you hallucinations and affect your general awareness, while Bisacodyl gets you properly hooked,” she explains. “I know girls who were so hooked on bisac they couldn’t pee without it.”

Nadezhda from St. Petersburg says she tried nearly all of these drugs. “All my life, I’ve been fighting my body — trying to make it fit the beauty standards I learned not only from magazines, but from my favorite books. When I was jogging or sleeping, or even when I received love letters, I felt ugly and ‘underbred,’ as if I were a horse without the right to lead a normal life,” she says. When Nadezhda took Fluoxetine, she told Meduza, she would eat one apple in six days and then on the seventh day she would find herself in the kitchen and “eat anything,” from stale bread to cold grits. “Furocemide had me spending half my time on the toilet and gave me cramps,” she says. “But the worst was when I tried metformin, a drug that diabetics use to lose weight. It can make the glucose in your blood drop sharply. I knew it but I still did it. And then I found myself over the toilet with stomach spasms, terrified for my life. I thought I was going to die and they would have to break the lock to get to me.”

Prescriptions from Vkontakte

Before she became a doctor, Yulia Sibagatullina worked the night shift at a drugstore. “Of course, when young girls came in to get something like that, it was obvious why they wanted it,” she recalls. “Though furosemide could also be for a grandmother. I often refused, explaining how dangerous it was, but most likely they just went and got it at another drugstore.”

Most of the medications young women take to lose weight in Russia are sold over the counter, but furosemide and special treatments for obesity and depression are prescription drugs. Young women told Meduza that it was still possible a few years ago to get fluoxetine without a prescription, if you tried enough drugstores. The first two or three might refuse, but eventually somebody would sell it to you. These days, they say, it’s no longer possible to hand a pharmacist a slip of paper with handwritten drug names and claim that it’s “from the doctor.”

In September 2017, the Health Ministry tightened the rules on the sale of antidepressants, redesigning the prescription form and instituting a rule that pharmacists must hold onto the scripts when selling prescription medicine to individuals without chronic illnesses (to stop patients from re-submitting the same documents at other facilities).

Despite these reforms, Russians can still buy these drugs through online communities dedicated to eating disorders. In these groups, you often see posts advertising “Flu for sale” (Fluoxetine) or “prescriptions in Ufa.” Meduza wrote an email to an address listed in one of these posts and got the following reply: the fluoxetine would be ready for pickup the following day and would cost 1,000 rubles (about $17 — ten times more than the drug’s retail price).

Meduza managed to contact one of the young women who sells fluoxetine through Vkontakte. She works at a drugstore and says most of her competitors do, as well. She sells the drugs at an 800-1,000-percent markup, explaining that it’s hard to keep accounts up and running long enough to do any business, because sellers’ Vkontakte pages are blocked as soon as users complain. The woman told Meduza that her main goal is to help people with “psychological issues” who are forced to turn to the black market. Most of these people can’t afford to see a psychiatrist, she says. (Where she lives, the woman says a single visit to a psychiatrist can cost as much as a quarter of someone’s average monthly rent.) At state clinics, the waiting list for a psychiatrist can be as long as a month. She says she met with a state-provided psychiatrist to discuss her depression, and the doctor prescribed her motherwort tea and and referred her to a hospital where she was treated with sleeping pills. The woman told Meduza that she doesn’t approve of using antidepressants to lose weight, but she says she never asks her customers why they need the medicine.

Meduza reached out to seven producers of antidepressants and ephedrine-based medications in Russia. All of them declined to comment on this story. A source at one of these pharmaceuticals told Meduza that the companies have no way to combat the black market that's emerged for these products. Responsibility for illegal sales falls on pharmacies and hospitals, the source said. Meduza spoke to several doctors who concurred with this assessment.

According to Nadezhda who has overcome her eating disorder and now works at a large state hospital in St. Petersburg, drugstore pharmacists often sell small supplies of medications to individuals without prescriptions. You don’t need to work at a drugstore, moreover, to sell medicine through Vkontakte — it’s enough to know someone who works there. Anyone with remedial image-editing skills can also learn to fake prescriptions.

Help can be hard to find

The misuse of medications is hardly unique to Russia, and every country addresses the problem in its own way. Alexandra Kupavskaya, a psychologist at the British Psychological Society, says there are no drugs for weight loss on England’s open market. “Antidepressants are under strict prescription control and you can’t really prescribe them to yourself. All the doctors have licenses that are very easy to lose, so strong medication is prescribed only cautiously,” she explains. “Many of us know what it’s like when you feel awful and they won’t prescribe that antibiotic you were so used to in Russia.” Kupavskaya says the problem is more acute in the U.S., where pharmaceutical companies are more powerful and “push doctors to prescribe more.”

“American TV shows a lot of ads for prescription drugs with catchy promises like ‘I took it, and life got better,’ or ‘Take it and feel your energy return’ — all of them ending with ‘Ask your doctor about this,’” says Kupavskaya. “I don’t know if weight-loss medication is advertised in the same way, but ads for antidepressants, painkillers, and cardiovascular medication are non-stop.” American research publications view laxative abuse as a facet of bulimia. English-language social networks also have eating disorder communities.

According to psychoanalyst Yuila Ovchinnikova, who works in London, it’s possible to get these drugs in Europe, as well. People simply ask friends to bring them from other countries where it’s easier to buy medication without prescriptions, she says. And food supplements, teas for weight loss, laxatives, and diuretics are available without a prescription. “People mostly buy laxatives and protein bars. The pharmacist will ask them what they need them for, but people with eating disorders can be very inventive,” she says.

Pyotr Skripchenko, a clinical psychologist who has studied and worked in France for the last 12 years, told Meduza that the pharmaceutical black market exists everywhere. “I come across these cases all the time,” he says. “Girls go to any lengths to lose weight or to keep it below the norm. An eating disorder is a real psychiatric disorder when the person has no understanding of the risks of medication abuse. Both here and in Europe, you can buy a lot of drugs without a prescription. Doctors — especially physicians who lack past experience with these patients — can be fooled and drugs can be abused.”

“There is the contagion effect, of course. It works according to the same principles as marketing or the spread of a cult. It most powerfully affects people who have experienced trauma, violence, or emotional suppression. Influencing people through eating habits is actually a common thing in cults. It’s a way to unite people under the same rules,” says Alexander Isaev, a psychologist who works with eating disorders at the “School of Eating,” an NGO in St. Petersburg. From 2013 until 2017, the school provided free meetings and consultations to people with eating disorders. The organization says it worked with as many as 1,000 people every year. The group was awarded several state grants, but most of its services were still offered by volunteers who organized lectures, psychological consultations, and training sessions. During “fairytale therapy,” for example, patients would discuss their problems while impersonating a well-known fairytale character. The funding dried up, however, and meetings are no longer regular, as the organization has no fixed venue or schedule.

People who realize they have a disorder often join self-help support groups. Every year, more and more communities “break away” from the anorexia groups, forming recovery communities like “A Different Reality,” “Notes on Problems With Eating,” “Help for Eating Disorders,” and others. These groups provide a space for young women to share their stories. Anastasia Lisitsa, who manages a community called “Pretty Girls Eat!” told Meduza that she set out to create an alternative to the group “Typical Anorexic.” “I previously suffered from an eating disorder and I know that people often try to help, but they go about it all wrong. For instance, they try forcing a person to eat. Finding help can be hard,” says Anastasia. “When I had my problem several years ago, I couldn’t find a community like ours. There were body-positive groups, but I felt it wasn’t really the same thing.”

According to research, eating disorders are hard to treat with medication, and the more common approach is psychotherapy. In large Russian cities, people who recognize their eating problems have few options. They can go to a private clinic, a local state psycho-neurological hospital, and in some cases an NGO. Private therapists are usually expensive — especially for students and schoolgirls who often hide the problem from their families. The attitudes at state clinics, according to the women who spoke to Meduza, are unpredictable: some will treat women as outpatients and hand over free medication, while other only schedule a single 10-minute appointment.

There are very few NGOs who work with these patients and they often collapse due to a lack of funding before long, and their enthusiastic founders eventually throw in the towel and return to their previous careers. This is what happened to the “School of Eating.” When the government grants ran out, an attempt to fund the organization through crowdfunding netted a mere 8,000 rubles ($140).

“An eating disorder is an illness that damages your personality. And you can’t reverse the damage without the help of a specialist,” warns Alexander Isaev. “You can’t just resolve to start eating well and expect recovery.” He says psychologists can help address the problem at an early stage, but psychiatric care is needed once the illness has developed further. After treatment, moreover, patients need to be monitored. Small NGOs like the “Women’s Support Group,” “Food Dependent Anonymous,” and “Overeaters Anonymous” are available in big cities like Moscow and St. Petersburg, but finding help can be difficult in Russia’s more remote regions, where the only option is often the Internet.

Isaev says he’s currently organizing mutual support groups to make up at least in part for the events lost when the School of Eating closed its doors. “People just talk about their problem for 20 minutes, and they can give each other a hug,” he explains.

It’s been five years since Natalya from St. Petersburg first sought psychiatric help. She credits her busy work schedule with leaving her too little free time for self-destruction, and she says she stopped reading comments in anorexia groups and turned to body-positive blogs and books, like The Beauty Myth by Naomi Wolf. When she began her treatment, she had teeth marks on her knuckles that never healed. She was diagnosed with reflux, hiatal hernia, and gastritis. “I’m getting treatment now. I’m seeing a psychiatrist and a gastroenterologist,” she says. “I haven’t taken any of the drugs for several years, but I often overeat and nearly always feel hungry.”

Natalya says she still has bouts of self-disgust about her own body. The feeling never went away.

Story by Marina Vasileva in St. Petersburg, translation by Alexandra Besedina