How do Eating Disorders Present in Males?
As a field, we are beginning to understand that males are at a high-risk for eating disorders and that it is crucial to understand how males present with eating disorders and how we can treat them. Realizing that men have eating disorders is extraordinarily important. Eating disorders are serious and potentially life-threatening and unfortunately, they are often overlooked and trivialized.
The reality of the eating disorder world is that the diagnoses of eating disorders have historically been based on women. Studies to define what eating disorders are have been done primarily with women. The criteria used to describe eating disorders has been normed to women. The professional field is primarily women and treatment is often designed with a gender bias. However, we are very aware that men (and people of all genders) can get eating disorders and that more men are presenting with symptoms and entering treatment. As a result, we have a lot of work to do to truly understand how males present with eating disorders.
To give an example of how eating disorder treatment is normed to women, we can look at current eating disorder screening tests. Typically, there are statements such as these where a client can answer yes or no.
- I think my thighs are too big.
- I think my buttocks are too large.
- I have trouble expressing my emotions.
- I am preoccupied with a desire to be thinner.
It is unlikely that a male teen, for example, will answer yes to these questions. In addition, 75% of eating disorder studies are conducted with only women. As a result, we have to look carefully at what it means to be a male with an eating disorder.
We know eating disorder rates in boys and men are significant—at least 1/3 of the prevalence in women. While we think that there are anywhere from 4-6 million men with eating disorders in America, only 1 in 10 people getting eating disorder treatment are male.
With the lack of education around males with eating disorders, it is important to understand the presentation of the illness in men. We think the age of onset in men is typically 14-16 years old. In a study of over 40,000 men, 26% said they were overweight, 8% engaged in binge eating, 1.5% purged, 4% fasted, and 3% used laxatives. Men tend to exercise more and purge less.
However, men also express a greater desire to be more muscular and leaner – not necessarily weigh less. When eating disorders are perceived as illnesses characterized by a strong pursuit of weight loss, this may prevent many men from being diagnosed. As many as 1/3 anorexic men have tried to gain weight as they tried to decrease body fat. In a study of college men, men perceived themselves to be heavier than they actually were. In spite of this, when asked about the ideal body type, they chose a body with 25% more muscle. Overeating by males is seen as less problematic and more typical to male behavior, despite the nearly equal prevalence of binge eating disorder among women and men. Too often, overeating is seen as an innocuous behavior ascribed to men because they have “larger appetites.” Other differences in the presentation of eating disorders in males include:
- Greater weight fluctuations.
- A pursuit of leanness and muscularity over thinness.
- Muscle belittlement: where men believe their musculature is inadequate.
- Less abuse of diet pills and laxatives.
- An increased prevalence of substance abuse disorders.
- A decreased likelihood to seek treatment.
50-60% of men with eating disorders engage in high-risk sports, sports like ballet, distance running, and other endurance and/or speed sports. These sports put men at risk for anorexia. Some sports like cheerleading, equestrian sports, swimming, wrestling, and football put men at risk for bulimia. In addition, there are certain sports that glorify eating disorders. Ski jumpers have extraordinarily low weight, jockeys are well-known to purge, cyclists are known to have eating disorder behaviors, and in bodybuilding and gymnastics, 1/3 of athletes engage in disordered eating. Up to 63% of wrestlers say they are preoccupied with body image and eating and at least 50% fast at least once a week.
In order to avoid missing 1/3 of the population of people with eating disorders, providers must become more educated on eating disorders in men and become aware of new literature on the prevalence and diagnosis. In addition, providers can accept that men may not connect the same way as women in therapy and adjust their services. Clinicians can make facilities and treatment centers more welcoming by showing men in advertising, paying attention to the language they use, and becoming literate on the needs of men in treatment. Going forward, it is important to conduct more research on males with eating disorders and to continue to work to expand services that are educated on the treatment of eating disorders in males.
ABOUT THE AUTHOR
Mark Warren, M.D.
Mark Warren is the chief medical officer of The Emily Program. He is also one of the original founders of the Cleveland Center for Eating Disorders, which became The Emily Program – Cleveland in 2014. A Cleveland native, he is a graduate of the Johns Hopkins University Medical School and completed his residency at Harvard Medical School. He served as Chairman of the Department of Psychiatry at Mt. Sinai Hospital and Medical Director of University Hospital Health System’s Laurelwood Hospital. A past vice-chair for clinical affairs at the Case School of Medicine Department of Psychiatry, he continues on the Clinical Faculty of the Medical School, teaching in both the Departments of Psychiatry and Pediatrics. He is currently a faculty member and former chair of the Board of Governors at the Gestalt Institute of Cleveland. Dr. Warren is a Distinguished Fellow of the American Psychiatric Association, a two-time recipient of the Exemplary Psychiatrist Award of the National Alliance for the Mentally Ill, and a winner of the Woodruff Award. He leads the Males and Eating Disorders special interest group for the Academy of Eating Disorders.