Recently, I met with a patient who I will call J. As we walked into my office for our first meeting, J’s thin, fragile body and eyes surrounded by dark circles spoke volumes. The family had decided to speak with a mental health provider after J’s mother found her child’s hair, falling away as a result of malnutrition, in the shower drain. In that first meeting, J described being plagued by worries about being “too fat” as well as a brutal exercise regimen, coupled with a diet highly restrictive in both calories and variety, intended to assuage that fear. In many ways, this is a run-of-the-mill description of a patient with an eating disorder. But what if I told you that J’s full name is Josh, and that he is a 14-year-old boy?
You may or may not be surprised. Certainly Josh’s father was. When I spoke with him the following week, he confided, through his tears, that he always thought that only “emotional teenage girls” develop anorexia nervosa. While a number of complex factors prevented the family from seeking treatment earlier, the belief that men and boys do not suffer from eating disorders as well as the stigma and shame associated with that possibility are important ones.
Eating disorders are often thought of as a “female problem.” Even researchers, advocates, and treatment providers who are aware that these disorders affect men and boys are plagued by misinformation. For example, it is often stated that 10% of individuals with EDs are male. As it turns out, this often-repeated statistic is highly problematic. When it was published 25 years ago, it represented the number of men and boys in treatment, not in the general population (Andersen, 1990). In fact, the best available data indicates that males account for 25% of individuals with anorexia nervosa and bulimia nervosa and 36% with binge eating disorder (Hudson et al., 2007).
As outlined in the first author’s book about males with anorexia nervosa (Wooldridge, 2016), the treatment process for patients with eating disorders can be divided into four stages: engagement, alliance building, diagnosis, and finally the ongoing treatment process itself. While we would refer readers to the book for a fuller discussion of each of these stages, here are a few comments about aspects of each particularly relevant to men and boys with eating disorders.
Engagement falters for two reasons. First, many men and boys fail to recognize that their behavior (weight loss, purging, binge eating, compulsive exercise, etc.) is a symptom of an eating disorder. And when they do recognize this, their help-seeking behavior is often hindered by stigma and shame. All too often, friends, family, and medical providers fail to recognize that they need urgent medical treatment. In one study, male patients with anorexia nervosa emphasized the lack of gender-appropriate information and resources for men as an impediment to seeking treatment (Räisänen & Hunt, 2014). Moreover, research shows that males are more likely to seek treatment at a later age than their female counterparts (Gueguen et al., 2012).
While the alliance-building process is crucial, it is also frequently given less attention that it deserves. Indeed, the importance of a strong working alliance has been clearly demonstrated for patients with eating disorders in particular (Antoniou & Cooper, 2013; Elvins & Green, 2008). For example, alliance was related to early weight gain as well as final outcome in adolescents with anorexia nervosa who are taking part in family-based treatment (Pereira, Lock, & Oggins, 2006). There are obstacles to the alliance-building process that are specific to men and boys with eating disorders. Stigma and shame often make the alliance-building process more difficult and should be addressed early in treatment. Stigma must be named and the layers of shame and embarrassment beneath acknowledged. An important aspect of addressing stigma is education.
Traditional constructions of masculinity often make the alliance-building more difficult. For example, men appear to hold more negative attitudes toward mental health treatment than their female counterparts (Andrews, Issakidis, & Carter, 2001). The effort to conform to socially prescribed gender roles prevents the expression of vulnerability and need for help (Galdas, Cheater, & Marshall, 2005). With this in mind, intervention should target normative beliefs (i.e., that other males don’t seek treatment), which are deeply related to the male experience of stigma and, thus, help-seeking behavior (Hammer, Vogel, & Heimerdinger-Edwards, 2013).
Assessment and diagnosis of eating disorders in males raises the question of what is an eating disorder and what is not (Darcy & Lin, 2012). The most important aspect of the diagnostic process involves recognizing that eating disorders are applicable, as a diagnostic category, to male patients. Two diagnoses deserve special mention in male populations. In recent years, muscle dysmorphia, a sub-classification of body dysmorphia, has gained attention. The distinguishing feature of muscle dysmorphia is the central role of muscularity-oriented, as opposed to thinness-oriented, body image concerns and behaviors (Murray, Rieger, Touyz, De la Garza Garcia, 2010). This disorder is characterized by an intense fear that one is insufficiently muscular and an excessive drive to enhance the visible appearance of muscularity. These patients are notable for working out and lifting weights excessively, as well as their extreme anxiety in the face of missed workouts (Murray, Rieger, Touyz, & De la Garcia Garcia, 2010).
Second, binge eating disorder is the most common eating disorder and affects more males than anorexia and bulimia combined. Binge eating disorder is characterized by episodes of bingeing and subsequent shame and guilt, after which the cycle repeats. All too often, health professionals address co-morbid symptoms, which include diabetes, high blood pressure and cholesterol, heart disease, gallbladder disease, osteoarthritis, and gastrointestinal problems (Bulik et al, 2003), without recognizing and treating the underlying eating disorder. Similarly, because of misinformation and stigma, men often think of binge eating as “normal guy” behavior.
While eating disorders in men and boys exist across ages and cultures, men and boys who identify as gay, bisexual, and transgender are at a higher risk of developing an eating disorder (Brown & Keel, 2012). The most widespread explanation for the increased incidence of eating disorders in the homosexual population is that gay men experience more body dissatisfaction than heterosexual men (Andersen, Cohn, & Holbrook, 2000). Indeed, the lean and muscular body type, which is difficult to achieve for most, is especially idealized by gay men. In addition, the transgender population merits further investigation as an especially high-risk category. In a recent study of college-aged youth, an eating disorder diagnosis as well as use of diet pills, vomiting, and laxative use were highest among transgender youth compared to heterosexual and homosexual women and women (Diemer, Grant, Munn-Chernoff, Patterson, & Duncan, 2015).
Once males and their families are engaged in treatment, a multidisciplinary and integrative approach to treatment is required to fully address all the factors that contribute to the patient’s eating disorder. Unsurprisingly, evidence clearly demonstrates better outcomes with an experienced multidisciplinary team than with efforts by a single clinician (Halmi, 2009; Mehler & Andersen, 1999). Treatment teams often consist of: psychologists, psychiatrists , social workers, primary care physicians, registered dieticians, and sometimes educators, clergy, even financial advisors to facilitate expensive inpatient treatment. In a similar vein, in an effort to address the complexity of the patient system, treatment should be integrative. Five relevant domains are identified: systemic, biological, cultural, psychodynamic, and spiritual (Wooldridge, 2016).
This emphasis on integrative treatment often stands in contrast with the emphasis on symptom-focused treatments that, while deeply valuable, may fail to acknowledge the underlying roots of patients’ struggles. Similarly, much has been made of the role of genetic vulnerability in patients with eating disorders. One compelling line of research suggests that the genetic vulnerability to an eating disorder ranges from 50 to 70 percent. Indeed, monozygotic twins share a 50 percent chance of having an eating disorder if one is afflicted (Bulik, Sullivan, Tozzi, Furberg, Lichtenstein, & Pedersen, 2006). At present, though, there is no conclusion as to what is being transmitted that causes genetic vulnerability. Furthermore, too much emphasis on genetic factors may impede the treatment process, as providers may overlook the role of other factors, such as underlying anxiety, depression, etc., dysfunction within family systems or psychodynamic meanings associated with food, weight, and shape, that can be directly addressed in the treatment.
In closing, let us return to Josh. The initial states of treatment consisted of educating Josh and his family about the fact that eating disorders don’t only happen to adolescent girls. A multidisciplinary treatment team, which included a psychiatrist, psychotherapist, and nutritionist, was engaged to address each aspect of Josh’s eating disorder. Josh’s parents were an integral component of the treatment team as well, essential to the process of helping him to normalize his eating and exercise. At the same time, Josh had a lot of work to do on his own. Although it took over a year for Josh’s weight to fully stabilize and several more years of treatment for his attitudes toward food, weight, and shape to fully normalize, Josh did achieve full recovery.