“Paris Thin”: A Call to Regulate Life-Threatening Starvation of Runway Models in the US Fashion Industry

“It is my job not to eat,” a runway model told the Vogue editor adjusting the set to allow her to lie down for the final set of photographs.¹ Her energy loss affected the set design, but not her ability to do her job. To the contrary, it was a qualification: a skeletal frame was essential to the look the designer had created. Indeed, the fashion industry refers to its top models as clothes hangers—the less mass within the outfit, the better the display, the better the employee. Not surprisingly, this takes a toll: models have died of starvation-related complications, sometimes just after stepping off the runway. France recently moved to criminalize this trend, prohibiting designers and agents from employing models with a body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) under 18. Similar measures exist in Israel, Milan, and Madrid, but France may become the first to be able to affect change. For one, the law has teeth, unlike municipal regulations that impose, at most, token fines. Secondly, and critically, France is the epicenter of the fashion industry while Israel barely leaves a footprint. In fact, France is so prominent in fashion that international models are referred to as “Paris thin,” a label indicating aesthetic eligibility to display haute couture.¹

Being Paris thin is undeniably hazardous; the average international runway model’s BMI is typically below the World Health Organization’s threshold for medically dangerous thinness for adults (16). Runway models are, by definition and professional necessity, starving to death. As one fashion editor explained, “the ideal body shape used as a starting point for a [designer’s] collection [is] a female on the brink of hospitalization from starvation.”¹ Not only does this threaten the livelihood of models, but it also perpetuates unrealistic—even deadly—expectations of what women and adolescent girls should look like to achieve the “perfect body.”

The workplace is often hazardous to health; the US government regulates the extent to which any other industry can expose employees to significant harm (e.g., mining, shipping, production lines). That it does not do the same for runway models is reflective of the idealization of skeletal women, which has detrimental effects beyond the workplace: anorexia nervosa has highest mortality rate of all mental illnesses in the United States (additional resources can be found in the Appendix, available as a supplement to the online version of this article at http://www.ajph.org).

The US Occupational Safety and Health Administration (OSHA), which regulates workplace hazards that create a significant risk of material health impairment that can be mitigated, has authority to require modeling agents to protect against risk of starvation by prohibiting models below a given BMI (e.g., < 18 or the equivalent for minors) from participating in a runway show or photo shoot.² Such regulation would add protection for the health of models. For example, the average model (height = 5′9’’) would be required to maintain a weight of 122 pounds—very thin, but still two BMI units above the threshold of medically dangerous thinness in adults set by the World Health Organization.

Occupational health researchers have long recognized that some diseases and disorders occur at higher rates in certain occupational subgroups compared with the general population because of noxious workplace exposures (e.g., lung disease in coal miners and musculoskeletal disorders among garment factory workers). Professional fashion models are particularly vulnerable to eating disorders resulting from occupational demands to maintain extreme thinness; they exhibit elevated eating disorder symptoms and higher prevalence of medically concerning low BMI (i.e., BMI < 18 for women aged ≥ 18 years) relative to comparison groups of women not working as models.³

Any attempt to regulate the US fashion industry would be met with challenges. The industry would argue that (1) BMI is an arbitrary metric, (2) models are independent contractors and thus not eligible for OSHA protection, and (3) a BMI requirement violates the Americans With Disabilities Act. These arguments are strong at first blush, but would not defeat workplace regulation protecting fashion models. Yes, BMI is an imperfect measure of health, particularly for individuals with higher levels of muscle mass. Healthy BMI estimates also vary by geographic ancestry (e.g., Asian individuals seem to face health risks associated with being overweight at lower BMIs than other groups). Nonetheless, given the prevalence of starvation in the modeling industry (BMI typically < 16) and the health harms that models suffer as a consequence, BMI is a necessary indicator of being dangerously underweight. Indeed, when it comes to extremes, the deficiencies associated with BMI as a metric dwindle.

Yes, agents identify models as independent contractors, an employment category over which OSHA lacks regulatory authority.² Yet US courts do not defer to the language of a contract to determine whether an individual is an employee or an independent contractor; to do so would allow all employers to evade workplace regulation by labeling workers as the latter. Rather than the terms of a contract, the level of control exerted by the employer is the determinative factor: substantial control indicates an employer-employee relationship.⁴ Contracts between agencies and models provide for nothing if not control (a model cannot negotiate or enter into any modeling opportunity without her agent, who retains exclusive rights to her name and image and determines and distributes her wages [in dollars or in trade], after subtracting the agency’s take).⁵ Indeed this is precisely why regulation of agents would be most efficacious; designers and models alike rely heavily on them.

And finally, yes, in broad terms, the Americans with Disabilities Act precludes much regulation tied to BMI. The Americans With Disabilities Act⁶ prohibits most employers from discriminating against qualified employees because of a disability, defined as a condition that substantially limits a “major life activity,” which includes many functions negatively affected by anorexia nervosa (e.g., caring for oneself, eating, learning, reading, concentrating, thinking, communicating, and working). Yet a minimum BMI would not constitute discrimination under the Americans With Disabilities Act so long as it was implemented to protect employee health.⁶ If the BMI threshold were sufficiently low so as not to exclude healthy models with naturally unusually low BMIs (e.g., 18), it would not constitute a discriminatory workplace protection. Furthermore, the severity of anorexia nervosa weighs in favor of allowing for a BMI requirement to protect against starvation (courts consider severity in addition to duration, likelihood, and imminence of harm).⁷ Evaluation of any OSHA regulation changes would be essential to ensure intended effects—without serious unintended adverse effects—are achieved.

The fashion industry is irrefutably powerful—it drives commerce around the world and affects what we wear more than most consumers even realize. Regulating such an industry is extremely difficult; it is complicated to enforce laws against an industry that so seamlessly crosses national boundaries, not to mention into media, in which images can be manipulated endlessly. Yet the United States is in a unique position to apply its occupational standards to an industry of employees fleeting in and out of our borders. Paired with similar restrictions in France, OSHA regulations in the United States would shake the fashion industry, even if enforcement dollars were few and far between. Designers would be hard pressed to maintain a presence in the fashion industry without participating in the New York City and Paris Fashion Weeks. “Paris thin” need not be deadly thin.