Males with Eating Disorders: The Gender Factor
Most people associate eating disorders predominantly with girls and women. However, in the last 10 years there has been increasing recognition that males suffer from eating disorders as well. And there are important differences to consider in the ways eating disorders start in males, how they evolve clinically, and what treatment approaches are most effective.
Boys and girls are equally dissatisfied with their bodies. Girls primarily desire to be thinner. By ninth grade, 70 percent of girls think of themselves as fat and most of these are dieting, even though perhaps only 10 percent are actually medically obese. Boys by mid-high school are also almost equally dissatisfied with their bodies. Half of them want to gain weight, usually as muscle without any fat. An equal or smaller number want to lose weight, also with a goal of developing lean muscularity.
Boys tend to be dissatisfied with their bodies from the waist up, while girls are dissatisfied with their waists down. Young women see themselves as normal in weight only when they are actually 13–15 percent below average. Men tend to see themselves as fat when they are actually 10–20 percent above average. All through development, boys and girls learn very different messages about what to consider normal or desirable in body weight and shape.
A young woman does not need any particular personal reason to diet. It’s enough to simply say, “I should take off a few pounds. I’m starting a diet tomorrow.” Dieting for women is culturally normative. This is not necessarily good, but it’s true. Our culture does not endorse dieting in boys for no special reason. The four most common reasons boys and young men diet are: first, to avoid being teased for being fat; second, to improve sports performance; third, to avoid getting diseases they see in their fathers and associate with being overweight (even when they are decades away from medical risk); and last, to enhance a gay relationship.
Social Factors Differ for Males
Studies of the prevalence of eating disorders among the general population show a ratio of about two females to every one male suffering from some form of anorexia nervosa, and a 3-to-1 ratio of females to males suffering from full or partial bulimia nervosa. In marked contrast to these figures, the gender ratio of patients coming to clinics for treatment is 10 or 20 females to 1 male. This means there’s a tremendous gap between the number of males who suffer from an eating disorder and those who receive treatment. The reasons for this disparity have not been identified, but probably involve a combination of prevalent stereotypes; a lack of knowledge by clinicians about the occurrence of eating disorders in males;and shame, fear, or guilt on the part of males, especially the fear of feeling weak and unmanly and being told they have “a girl’s disease.” Another factor is that very few of the major treatment centers accept males into their programs.
Girls who engage in sports that demand thinness for both performance and appearance ratings are most likely to suffer an eating disorder. Such sports include gymnastics, figure skating, and ballet. For boys, thinness is associated with fewer sports—generally only when it improves functioning. Such sports include cross-country running (not sprinting), lightweight rowing, and figure skating. A football player can’t be too big, as long as he can handle his weight on the field.
One of the reasons that eating disorders are more prevalent among girls is the unhappy fact that they are more likely to be brought up with the belief that appearance, especially thinness, is an end in itself. For boys, changes in body weight and shape are more often desired to achieve a goal of functioning differently, rather than striving for an altered appearance as an end in itself.
Common Types of Male EDs
The most recently recognized subtype of eating disorder, and probably the most common, is binge eating disorder (BED). It is characterized by binge episodes without any self-induced vomiting, abuse of laxatives, or other dramatic means of compensation for the excess calories. BED is found almost equally in males and females. It is estimated that about 25 percent of medically obese individuals, male or female, suffer from BED. A diagnosis of BED with obesity is important because the medical obesity can seldom be treated until the BED is treated.
Another dramatic and almost exclusively male eating disorder is “reverse anorexia” or “muscle dysmorphia,” as described in The Adonis Complex. In this disorder, a teenage or young adult male perceives himself to be thin, puny, and underdeveloped even when he has massive, well-developed muscles and virtually no fat. This perception, despite obvious muscularity, often leads to steroid abuse as a way to become still larger and more muscular.
The treatment of eating disorders in males and females is similar in many ways: 1) Stop the abnormal behavior, whether it is excessive food restriction, binge-purge activity, or compulsive exercise; 2) Identify and change the core distorted beliefs that make weight loss or shape change an excessive or exclusive source of self-esteem and replace these cognitive distortions with a healthy, balanced view of self; 3) Develop the skills to live sanely in a weight-obsessed society; 4) Restore weight to normal if underweight; and 5) Treat the companion disorders of depression, anxiety, and obsessive-compulsive disorder, which co-occur with more than 50 percent of all eating disorders. The core validated form of psychotherapy for eating disorders is cognitive-behavioral therapy, sometimes accompanied by antidepressants.
Boys and men also need and benefit from the chance to meet in groups just for guys, led by male clinicians. The topics initially discussed in men’s groups are those that appear unsafe to talk about in mixed groups in which men are a minority: sports, cars, hunting, fishing, rock groups. Soon, however, the men will begin to probe into deeper issues, such as poor relationships with their fathers and their fears about women.
Whether it is therapeutic to increase to normal the low testosterone that comes with weight loss in anorexic males is a controversial issue. In anorexic males who have completed most of their growth, early normalization of testosterone may help them achieve a more typical male body compensation as they restore weight, rather than taking on excessive abdominal weight.
It is very helpful for these young men to receive instruction from a certified trainer who can start them on a lifetime program that combines moderate regular aerobics with progressive strength training and emphasizes good form with light weights. This exercise training gives males with eating disorders a strong sense of taking charge of their lives and contributing to their own wellness and body composition, rather than simply “being fixed” by someone else.
Boys and men suffer from eating disorders more often than commonly recognized. Their goals for weight and shape-change, their strategies for achieving their goals, their body image ideals, the obstacles they face in coming for treatment, and the ways they receive treatment, all differ significantly from those of girls and women. Understanding this and becoming savvy about identifying and guiding boys and men to experienced therapists who can work with their specific needs should become a priority for our society and health care systems.
Arnold E. Andersen, M.D.
Reprinted with permission from Eating Disorders Recovery Today
Spring 2004 Volume 2, Number 3
©2004 Gürze Books
About the Author
Arnold Andersen, M.D., Professor of Psychiatry at the University of Iowa College of Medicine, is the world’s foremost authority on males and eating disorders. He is the co-author of Making Weight: Men’s Conflicts with Food, Weight, Shape & Appearance and three other books on eating disorders.