Men with Eating Disorders

Eating Disorders: Not For Females Only

It is generally assumed that the problem of eating disorders is a female issue because, after all, appearance, weight, and dieting are predominately female preoccupations. Magazine articles, television shows, movies, books, and even treatment literature dealing with eating disorders focus almost exclusively on females.

Binge eating disorder is seen somewhat differently than the classic eating disorders anorexia nervosa and bulimia nervosa. Males have always been included in the literature and in treatment programs for compulsive overeating. Compulsive overeating, however, has only recently been recognized as its own eating disorder - binge eating disorder - and it still is not accepted as an official diagnosis. Because anorexia and bulimia are official diagnoses, the term eating disorder usually refers to one of these two disorders.

Males do develop anorexia and bulimia, and, rather than being a new phenomenon, this was observed over three hundred years ago. Among the first well-documented accounts of anorexia nervosa, reported in the 1600s by Dr. Richard Morton and in the 1800s by the British physician William Gull, are cases of males suffering from the disorder. Since these early times, eating disorders in males have been overlooked, understudied, and underreported. Worse still, eating disordered males seeking treatment are turned down when requesting admission to most of the programs in the country because these programs treat females only.

The number of females suffering from eating disorders far exceeds that of males, but in the last few years reported cases of males with anorexia nervosa and bulimia nervosa have been steadily increasing. Media and professional attention have followed suit. A 1995 article in the Los Angeles Times on this subject entitled "Silence and Guilt" stated that roughly one million males in the United States suffer from eating disorders.

A 1996 article in the San Jose Mercury News shocked readers by reporting that Dennis Brown, a twenty-seven-year-old Super Bowl defensive end, revealed that he used laxatives, diuretics, and self-induced vomiting to control his weight and even underwent surgery to repair bleeding ulcers made worse by his years of bingeing and purging. "It's always been the weight thing," said Brown. "They used to get on me for being too big." In the article, Brown reported that after making such statements in an NFL-sponsored interview session, he was pulled aside and reprimanded by coaches and team officials for ". . . embarrassing the organization."

The following research summaries, provided by Tom Shiltz, M.S., C.A.D.C., from Rogers Memorial Hospital's Eating Disorder Center in Oconomowoc, Wisconsin, are included here to provide insight into the various biological, psychological, and social factors influencing male eating disorders.

• Approximately 10 percent of eating disordered individuals coming to the attention of mental health professionals are male. There is a broad consensus, however, that eating disorders in males are clinically similar to, if not indistinguishable from, eating disorders in females.
• Kearney-Cooke and Steichen-Asch found that men with eating disorders tend to have dependent, avoidant, and passive-aggressive personality styles and to have experienced negative reactions to their bodies from their peers while growing up. They tend to be closer to their mothers than to their fathers. The authors concluded that "in our culture, muscular build, overt physical aggression, competence at athletics, competitiveness, and independence generally are regarded as desirable for boys, whereas dependency, passivity, inhibition of physical aggression, smallness, and neatness are seen as more appropriate for females. Boys who later develop eating disorders do not conform to the cultural expectations for masculinity; they tend to be more dependent, passive, and non-athletic, traits which may lead to feelings of isolation and disparagement of body."
• A national survey of 11,467 high school students and 60,861 adults revealed the following gender differences:
  • Among the adults, 38 percent of the women and 24 percent of the men were trying to lose weight.
  • Among high-school students, 44 percent of the females and 15 percent of the males were attempting to lose weight.
• Based on a questionnaire administered to 226 college students (98 males and 128 females) concerning weight, body shape, dieting, and exercise history, the authors found that 26 percent of the men and 48 percent of the women described themselves as overweight. Women dieted to lose weight whereas men usually exercised.
• A sample of 1,373 high-school students revealed that girls (63 percent) were four times more likely than boys (16 per-cent) to be attempting to reduce weight through exercise and caloric intake reduction. Boys were three times more likely than girls to be trying to gain weight (28 percent versus 9 per-cent). The cultural ideal for body shape for women versus men continues to favor slender women and athletic, V-shaped, muscular men.
• In general, men appear to be more comfortable with their weight and perceive less pressure to be thin than women. A national survey indicated that only 41 percent of men are dissatisfied with their weight as compared with 55 percent of women; moreover, 77 percent of underweight men liked their appearance as opposed to 83 percent of underweight women. Males were more likely than females to claim that if they were fit and exercised regularly, they felt good about their bodies. Women were more concerned with aspects of their appearance, particularly weight.
• DiDomenico and Andersen found that magazines targeted primarily to women included a greater number of articles and advertisements aimed at weight reduction (e.g., diet, calories) and those targeted at men contained more shape articles and advertisements (e.g., fitness, weight lifting, body building, or muscle toning). The magazines most read by females ages eighteen to twenty-four had ten times more diet content than those most popular among men in the same age group.
• Gymnasts, runners, body builders, rowers, wrestlers, jockeys, dancers, and swimmers are vulnerable to eating disorders because their professions necessitate weight restriction. It is important to note, however, that functional weight loss for athletic success differs from an eating disorder when the central psychopathology is absent.
• Nemeroff, Stein, Diehl, and Smilack suggest that males may be receiving increasing media messages regarding dieting, ideal of muscularity, and plastic surgery options (such as pectoral and calf implants).

The increase in articles and media reports on males with eating disorders is reminiscent of the early years when eating disorders in females first began to get public attention. One wonders if this is our early warning of how frequently the problem with males really occurs.

The studies indicating that somewhere between 5 and 15 percent of eating disorder cases are males are problematic and unreliable. Identifying males with eating disorders has been difficult for several reasons, including how these disorders are defined. Consider that until DSM-IV, the diagnostic criteria for anorexia nervosa included amenorrhea, and since originally bulimia nervosa was not a separate illness but rather absorbed into the diagnosis of anorexia nervosa, a gender bias existed for both of these disorders such that patients and clinicians held the belief that males do not develop eating disorders.

Walter Vandereycken reported that in a 1979 study, 40 percent of internists and 25 percent of psychiatrists surveyed believed that anorexia nervosa only occurs in females, and that in a 1983 survey 25 percent of psychiatrists and psychologists considered femaleness fundamental to anorexia nervosa. Being overweight and overeating are culturally more acceptable and less noticed in males; therefore, binge eating disorder also tends to go underrecognized.

As it now stands, the three essential requirements for the diagnosis of anorexia nervosa - substantial self-induced weight loss, a morbid fear of becoming fat, and an abnormality of reproductive hormone functioning - can be applied to males as well as females. (Testosterone levels in males decrease as a result of this disorder, and in 10 to 20 percent of cases, males remain with features of testicular abnormality.) The essential diagnostic features for bulimia nervosa - compulsive binge eating, a fear of fatness, and compensatory behaviors used to avoid weight gain - can also be equally applied to males and females.

For binge eating disorder, both males and females binge eat and feel distress and out of control over their eating. However, the problem of identification continues. Males with eating disorders have been so rarely acknowledged or encountered that the diagnostic possibility of anorexia nervosa, bulimia nervosa, or binge eating disorder is overlooked when males present with symptoms that would lead to a correct diagnosis if presented by a female.

Diagnostic criteria aside, the problem of identifying males with eating disorders is heightened by the fact that admitting to an eating disorder is difficult for anyone, but even more difficult for males due to the perceived notion that only females suffer from these illnesses. In fact, males with eating disorders commonly report fears of being suspected of homosexuality for having what is considered a "female problem."

Gender Identity and Sexuality

As far as the sexuality issue goes, males with all variations of sexual orientations develop eating disorders, but studies have indicated a possible increase in gender identity conflict and sexual orientation issues among many males who do develop eating disorders. Dieting, thinness, and obsession about appearance tend to be predominantly feminine preoccupations, so it is not surprising that male eating disorder patients often present with gender identity and orientation issues including homosexuality and bisexuality. Tom Shiltz has also compiled the following statistics on sexuality, gender identity, and eating disorders, reprinted here with his permission.

Gender Dysphoria and Homosexuality

• Fichter and Daser found that male anorexics saw themselves and were seen by others as more feminine than other men, both in attitudes and behavior. In general, the patients appeared to identify more closely with their mothers than their fathers.
• Homosexuals are overrepresented in many samples of eating disordered men. While the proportion of male homosexuals in the general population cross-culturally is estimated to be 3 to 5 percent, samples of eating disordered men are commonly twice as high or higher.
• Several authors have noted that homosexual content preceded the onset of the eating disorder in up to 50 percent of male patients.
• Conflict over gender identity or over sexual orientation may precipitate the development of an eating disorder in many males. It may be that by reducing their sexual drive through starvation, patients can temporarily resolve their sexual conflicts.
• Body image concerns may be important predictors of eating disorders in males. Wertheim and colleagues found that a desire to be thinner was a more important predictor of weight loss behaviors than psychological or family variables for both male and female adolescents.
• Kearney-Cooke and Steichen-Asch found that the preferred body shape for contemporary men without eating disorders was the V-shaped body, whereas the eating disordered group strove for the "lean, toned, thin" shape. The authors found that most of the men with eating disorders reported negative reactions from their peers. They reported being the last ones chosen for athletic teams and often cited being teased about their bodies as the times when they felt most ashamed of their bodies.

Sexual Attitudes, Behaviors, and Endocrine Dysfuncion

• Burns and Crisp found that male anorexics in their study admitted "obvious relief" at the diminution of their sexual drive during the acute phase of their disease.
• A study by Andersen and Mickalide suggests that a disproportionate number of male anorexics may have persisting or preexisting problems in testosterone production.

One problem with eating disorder and gender studies is that what are often considered feminine traits, such as a drive for thinness, body image disturbance, and self-sacrifice, are the hallmarks of eating disorders in both males and females. Therefore, using these traits to determine the degree of femininity in anyone with an eating disorder, male or female, is misleading. Furthermore, many studies involve self-reporting and/or populations in eating disorder treatment settings, both of which may provide unreliable results. Since many individuals find it difficult to admit they have an eating disorder, and since the admission of homosexuality is also a difficult matter, the actual incidence of homosexuality among males with eating disorders in the general population is an unclear and undetermined issue.

Andersen and other researchers, such as George Hsu, agree that the most important factor may be that there is less reinforcement for slimness and dieting for males than for females. Dieting and weight preoccupation are precursors for eating disorders and these behaviors are more prevalent in females. Andersen points out that by a ratio of 10.5 to 1, articles and advertisements concerning weight loss are more frequent in the ten most popular women's versus men's magazines.

It is more than interesting that the 10.5 to 1 ratio parallels that of women to men with eating disorders. Furthermore, in subgroups of males where there is a great emphasis on weight loss - for example, wrestlers, jockeys, or football players (such as in the above-mentioned case of Super Bowl defensive end Dennis Brown), there is an increased incidence of eating disorders. In fact, whenever weight loss is required for a particular group of individuals, male or female, such as in ballerinas, models, and gymnasts, there is a greater likelihood that those individuals will develop eating disorders. From this it can be speculated that as our society increasingly places pressure on men to lose weight, we will see an increase in males with eating disorders.

In fact, it is already happening. Men's bodies are more frequently the targets of advertising campaigns, leanness for men is increasingly being emphasized, and the number of male dieters and males reporting eating disorders continues to rise.

One final note is that, according to Andersen, eating disordered men differ from eating disordered women in a few ways that may be important for better understanding and treatment.

• They tend to have genuine histories of pre-illness obesity.
• They often report losing weight in order to avoid weight-related medical illnesses found in other family members.
• They are likely to be intensely athletic and to have begun dieting in order to attain greater sports achievement or from fear of gaining weight because of a sports injury. In this respect, they resemble individuals referred to as "obligatory runners." In fact, many eating disordered men may fit another proposed but not yet accepted diagnostic category, referred to as compulsive exercise, compulsive athleticism, or a term coined by Alayne Yates, activity disorder. This syndrome is similar to but separate from the eating disorders and is discussed in this book in chapter 3.

Treatment and Prognosis for Males

Although more research needs to be done on the specific psychological and personality features of males with eating disorders, the basic principles for treatment currently promoted are similar to those for treating females and include: cessation of starvation, stop binge eating, weight normalization, interrupting binge and purge cycles, correcting body image disturbance, reducing dichotomous (black-and-white) thinking, and treating any coexisting mood disorders or personality disorders.

Short-term studies suggest that the prognosis for males in treatment is comparable to that for females, at least in the short term. Long-term studies are not available. However, empathetic, informed professionals are necessary, due to the fact that males with eating disorders feel misunderstood and out of place in a society that still doesn't understand these disorders. Even worse, males with eating disorders are often made to feel uncomfortable and otherwise rejected by females similarly afflicted. Although it may turn out to be true, it is often mistakenly assumed that males with eating disorders, most particularly anorexia nervosa, are more severely disturbed and have a poorer prognosis than females with such disorders.

There are good reasons why this may appear to be the case. First, since males often go undetected, only the most severe cases come into treatment and thus under scrutiny. Second, there seems to be a contingent of males with other serious psychological disorders, most notably obsessive-compulsive disorder, where food rituals, food phobias, food restriction, and food rejection are prominent features. These individuals end up in treatment mostly due to their underlying psychological illnesses, not for their eating behavior, and they tend to be complex, difficult-to-treat cases.

Strategies for Prevention and Early INtervention of Male Eating Disorders

• Recognize that eating disorders do not discriminate on the basis of gender. Men can and do develop eating disorders.
• Learn about eating disorders and know the eating disorder warning signs. Become aware of your community resources (e.g., eating disorder treatment centers, self-help groups, etc.). Consider implementing an Eating Concerns Support Group in the school setting to provide interested young men with an opportunity to learn more about eating disorders and to receive support. Encourage young men to seek professional help if necessary.
• Athletic activities or professions that necessitate weight restriction (e.g., gymnastics, track, swimming, wrestling, rowing) put males at risk for developing eating disorders. Male wrestlers, for example, present with a higher rate of eating disorders than the general male population. Coaches need to be aware of and disallow any excessive weight control or body building measures employed by their young male athletes.
• Talk with young men about the ways in which cultural attitudes regarding ideal male body shape, masculinity, and sexuality are shaped by the media. Assist young men in expanding their idea of "masculinity" to include such characteristics as caring, nurturing, and cooperation. Encourage male involvement in traditional "nonmasculine" activities such as shopping, laundry, and cooking.
• Never emphasize body size or shape as an indication of a young man's worth or identity as a man. Value the person on the "inside" and help him to establish a sense of control in his life through self-knowledge and expression rather than trying to obtain control through dieting or other eating disorder behaviors.
• Confront others who tease men who do not meet traditional cultural expectations for masculinity. Confront anyone who tries to motivate or "toughen up" young men by verbally attacking their masculinity (e.g., "sissy" or "wimp"). Dem-onstrate respect for gay men and men who display personality traits or who are involved in professions that stretch the limits of traditional masculinity (e.g., men who dress colorfully, dancers, skaters, etc.).
• Research has shown that a man who develops an eating disorder presents the following profile: he appears to lack a sense of autonomy, identity, and control over his life; he seems to exist as an extension of others and to do things because he must please others in order to survive emotionally; and he tends to identify with his mother rather than with his father, a pattern that leaves his masculine identity in question and establishes a repulsion of "fat" that he associates with femininity. With this in mind, the following suggestions for prevention can be made:
  • Listen carefully to a young man's thoughts and feelings, take his pain seriously, allow him to become who he is.
  • Validate his strivings for independence and encourage him to develop all aspects of his personality, not only those that family and/or culture find acceptable. Respect the person's need for space, privacy, and boundaries. Be careful about being overprotective. Allow him to exercise control and make his own decisions whenever possible, including control over what and how much he eats, how he looks, and how much he weighs.
  • Understand the crucial role of the father in the prevention of eating disorders and find ways to connect young men with healthy male role models.

By Carolyn Costin, MA, M.Ed., MFCC - Medical Reference from "The Eating Disorders Sourcebook"

Source: Used with permission of Tom Schlitz, M.S., C.A.D.C., of the Rogers Memorial Hospital Eating Disorder Center.

With more time and research devoted to analyzing and understanding the sociocultural, biochemical, and gender-related factors in the roots of the problems of males with eating disorders, optimal prevention and treatment protocols will be revealed.

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