Eating Disorders in Men
Many people, including health care providers, assume that men (higher weight men at that) are not as vulnerable to eating disorders as women. Therefore, they often do not bother to screen male patients for eating disorders in the same way they might screen women. The assumption can be that men simply lack discipline and willpower and need to be instructed to "diet differently" or be "better at dieting."
Often, providers focus on the fact that their patient is gaining weight while ignoring clinically significant eating disorder symptoms. To make matters worse, restrictive diets — that can exacerbate binge eating — are often prescribed as the recommended “cure."
Many men that seek help in our eating disorder clinic struggle with binge eating for many years before seeking treatment. Our male patients tend to wait to seek help until they start experiencing serious health issues or significant functional impairments.
How do eating disorders present in males?
We know this about eating disorders—a biological or temperamental predisposition can be unveiled by external influences. Among males with eating disorders, premorbid patient characteristics include a history of obesity or being overweight, often with a history of weight-related teasing or bullying.
While eating disorders can and do occur at all stages of the lifecycle in males, puberty is a particularly common time for onset of the illness. In normal puberty, boys gain an average of 50 to 60 pounds and grow 12 to 14 inches.
Involvement in high-risk groups also characterizes many male eating disorder patients, including:
- Appearance-based jobs (modeling, acting)
- Food-related jobs
- Jobs traditionally held by women
- Sports where aesthetics relate to scoring or where there are weight requirements for performance or participation (ie. figure skating diving, gymnastics, body building, wrestling, swimming)
Regarding sexuality, there is a widespread misperception that eating disorders are more common in homosexual men. The reality is that most men with eating disorders are not gay, and most gay men do not have eating disorders.
However, homosexual men are over-represented in male patients with eating disorders. This may be due to several factors, including a culture of idealized bodies and greater pressure to be thin in the gay community, as well as increased body dissatisfaction, perhaps due to the internalized homophobia of a critical larger culture. Conflict regarding gender or sexual identity is a risk factor for eating disorders as well.
With regard to eating disorders in young boys, children with eating disorders are more likely to be males than adolescents with eating disorders. Selective (“picky”) eaters are more likely to be boys than girls, and the syndrome has been associated with later development anorexia nervosa.
Risk factors for early life feeding problems include neurodevelopmental problems (including autism spectrum disorders and sensory integration issues), medical comorbidities, and character traits (including being obsessional, anxious, easily overstimulated/distracted).
While all eating disorder symptoms occur in males, a 2012 study found that purposeful restriction was by far the most common behavior, demonstrated by 96 percent of men with eating disorders. 40 percent engaged in over-exercise, while only 23 percent engaged in purging (including laxative abuse) and 15 percent engaged in bingeing. (Norris et al, 2012)
What medical complications of eating disorders commonly occur in males?
The most serious medical complications of eating disorders are related to cardiac issues, frequently indicated by low heart rate. The previous change is important, because the low heart rate itself is not the medical problem, but an indicator of underlying medical problems.
The notion of the “athletic heart” is more prominent in males— they will often be told by misinformed health care providers that their low heart rate is due to their athletic pursuits. However, this explanation can and must be refuted by the practitioner screening for an eating disorder by performing a simple orthostatic BP/pulse. An athlete’s heart rate will not increase by 30 to 40 points from the act of lying down to standing up. The presence of other signs of energy conservation like lowered body temperature and cold extremities signs of energy conservation like lowered body temperature and cold extremities can also help refute the “athletic heart” rationale for low heart rate associated with eating disordered behaviors.
Endocrine dysfunction is another common medical complication of eating disorders in males. Low testosterone places males at increased risk for osteoporosis because this hormone is a protective factor against low bone mineral density. One study found that males at admission were more likely to have low bone mineral density and osteoporosis than females (Mehler, 2008).
Men tend to wait to seek help many years after eating disorder symptoms appear
Men tend to seek help for binge eating disorder because they are concerned about serious health issues that stem from binge eating habits and the associated weight gain (examples: diabetes, risk of limb amputation, high blood pressure and more). Conversely, women tend to seek treatment for binge eating earlier — often primarily due to concerns about weight and appearance.
Men struggle with body image, too
Like women, men also have body image issues. But this body image disturbance can look different. Men tend to focus on having a healthier body. They might want a more muscular physique while women want to be much slimmer. Men can also be less compulsive with body image disturbance related behaviors than women are. Women might weigh themselves multiple times over the course of 24 hours, check their body appearance and measurements frequently, and compare their body to other women. Men might practice more avoidance behaviors more frequently, such as avoiding weighing themselves or avoiding situations where they will be weighed. Men might also to avoid clothes shopping and wear clothes that are too big or avoid mirrors and reflective surfaces in which they would see their shape.
Eating disorders in men are underdiagnosed
Not only are men seriously underdiagnosed with eating disorders, but they are less likely to seek specialized binge eating disorder treatment from experienced clinicians. One of the problems that I see is that many primary care doctors and other providers are just not expecting male patients to have an eating disorder. Thus, they do not look for or screen for eating disorder behaviors.
Binge eating can reduce sexual functioning
I see many men with binge eating disorder struggle a great deal with sexual functioning. In fact, many of our male patients come to us for help because they want to improve their intimate lives with their partners. Concerns about intimacy can be related to body image issues, mood issues, behavior patterns, and/or medical issues associated with BED. In treatment, men can address these issues behaviorally and medically.
Men struggle emotionally, too, and benefit from therapy
Many male patients come to treatment and recognize that they have been struggling with comorbid depression, anxiety, and or addictive/compulsive behaviors for years. Men are not always socialized to sit and talk about their feelings in any setting let alone a group setting, but I’ve seen many of them discover the power and value of vulnerability and connection in a therapeutic setting.
Men might have different views about exercise
Since movement is often an important part of living a balanced life, it’s important to incorporate joyful movement into the binge eating disorder treatment setting. Men and women might focus on different things when it comes to exercise. In our treatment center, every patient in our treatment program works with an exercise physiologist and participates in daily movement groups. We sometimes see a man’s exercise goals looking very different from woman’s. Men might be very goal and performance driven when it comes to exercising. They will make goals regarding exercise: to run a 5K, to walk a mile without stopping or to be able to walk to work.
What can professionals do in their practices to support identification and treatment of eating disorders in males?
- Simply put, lack of awareness equals a lack of diagnosis. Just this year, a study confirmed the role of gendered constructions of eating disorders in delayed help-seeking in men and boys. Understand that eating disorders can and do occur in boys and men. Consider this a diagnosis even when your patient does not acknowledge an eating disorder—symptoms of this illness include denial, lack of awareness and ambivalence about treatment.
- Early intervention is critical to lasting recovery. Delayed treatment leads to bad outcomes—a 2012 study found that half of all male patients had to be admitted to the hospital for medical or psychiatric stabilization at initial presentation.
- The sooner a male patient’s eating disorder is treated, the better their prognosis and the less likely they patient will have long-term illness recurrence. A recent cohort study found that outcomes for all eating disorders were actually better among men than women when remission was measured by weight restoration and self-reported relapse (Stoving et al, 2001).
- Know your eating disorder treatment resources—both local and national—and assist in the coordination of referrals and post-discharge care.