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Presented by Dr. Brad Zehring, Founder of the Zehring Clinic
For decades, society has perpetuated the idea that eating disorders primarily affect young, white, thin girls and women; however, this is far from the truth. All genders, ages, and weights experience eating disorders, including boys and men. Unfortunately, men have historically been under-diagnosed and underrepresented in both research and treatment programs, which can be extremely harmful and stigmatizing.
Of all the mental health disorders, eating disorders are among the most female-centric, which has severely hurt research efforts and made screening and diagnostic tools female-focused.
For example, less than 1% of contemporary peer-reviewed journals on anorexia nervosa include male presentations.1 This is alarming and contributes to eating disorders being severely under-diagnosed in boys and men.
The criteria for eating disorders, especially anorexia nervosa, are also very gendered. Amenorrhea, or the absence of menstruation, was historically a hallmark of anorexia before the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, published in 2013. Consequently, most 20th-century literature doesn’t recognize anorexia among males because they didn’t fit the criteria. Plus, men don’t have the endocrine equivalent to amenorrhea. They may experience a loss of sexual interest and reduced testosterone levels, but these things are far more subjective and not seen in the literature itself.1
The research on eating disorders in men is pretty limited, but based on what we do know, the prevalence is:1
Keep in mind this is likely to be an underestimated prevalence due to female-centric research. And even when there are studies about males, these typically occur in a Western setting, and the patients are primarily adolescents and white.1 This is a very limited sample size that excludes people of color, older people, trans boys and men, and more.
Males with eating disorders are more likely than females with eating disorders to report a greater incidence of:1,2
When treating eating disorders in males, men may need more treatment planning related to emotional discussion and identification. They may have trouble identifying what is at the core or root of their eating disorder, and treatment can help them learn to speak a new language of self-expression.
Some men may enter treatment feeling defensive and viewing it as “anti-masculine,” so one challenge for treatment is helping men to acknowledge the eating disorder itself, de-stigmatize their condition, and increase readiness to accept treatment.
Men may feel ostracized in treatment spaces that aren’t gender-neutral. Sometimes the reading materials or packaging or how the treatment is discussed is not inclusive to males with eating disorders. It’s essential to have a diverse population of patients to decrease some of those barriers.
And while it may seem counterintuitive, safe and sensitive treatment does not mean male-only clinicians or male-only groups. Gender-segregated treatment may actually hurt the therapeutic process by creating a vacuum. Mixed-gender spaces encourage men to express their emotions and may make them feel less inhibited.
Eating disorder screening tools are female-focused and result in males being extremely under-diagnosed. Part of this can be attributed to how questions are asked on self-report assessments.
One study of high school students found that only 5% of boys reported overvaluation of body weight and shape compared to 24% of girls. But, upon looking closer, it was realized that overvaluation rates might be similar in both genders, but how the researchers asked the questions caused underreporting in boys.1
In girls and women, overvaluation of the body is usually associated with the thinness ideal. In contrast, men tend to have an overvaluation of weight and shape, but it’s predicated on the internalization of muscularity.
Moreover, using body weight as an indicator of eating disorder severity and medical risk may be unreliable in male patients since they are often focused on muscularity. Males with higher body weights may still be at a greater risk of osteoporosis and bone disease. Their purging behaviors may also be undetected because they tend to purge with excessive or compensatory exercise as opposed to self-induced vomiting or laxative use.3
The lifetime prevalence for males with anorexia is between 0.1% and 0.3% in the community and 5% and 11% in clinic settings.1 Men are at a higher risk of dying of anorexia due to receiving a diagnosis later in the course of their illness.
One study found that adolescent males reported episodes of extreme dietary restriction at least three times per week at a rate of 2.3%, a prevalence estimate lower than females at 11.5%. In this same sample, regular compulsive exercise was reported by 5.3% of males vs. 5.4% of females.1
Regarding caloric restriction, females do this in pursuit of thinness, while men pursue leanness or enhancing muscle definition. Males tend to be less concerned about weight than females and more concerned about shape, including broad shoulders, small waist, broad back, big legs, etc. Consequently, males with anorexia often present with higher admission BMIs than females.
Compulsive exercise tends to be the last symptom to remit and the first symptom to relapse in male eating disorder cases. Men are much more likely to experience physical distress than emotional distress, especially because compulsive exercise is linked to affect regulation—they use exercise to regulate their mood and emotions. Their exercise habits tend to be more rigid and rule-driven than that of females. And they may experience more intense mood swings if they can’t exercise or follow through on certain habits.
The prevalence of bulimia nervosa in males is between 0.1% and 0.5%, while between 1.1% and 4.6% of females are estimated to have bulimia.1
Males with bulimia report fewer eating concerns and lower loss of control than females with this condition. Females tend to experience a lot of shame related to their binging episodes, but men don’t tend to have the same connection between distress and binging, so it gets missed on standard assessments.
Another common presentation of bulimia in males is that of the cheat meal or cheat day. Many men with body image concerns related to muscularity may have a strict diet that prohibits certain foods or food groups, but one meal or day per week, they allow themselves to break the rules and eat whatever they want. Often, these meals can be 1,000 to 9,000 calories at a time.1
Binge eating disorder is the most common eating disorder among males.4
Among high school adolescents, 6% of male students and almost 17% of female students engaged in weekly objective binge eating per month.1 The disparity may be due to the fact that females more commonly report shame and guilt related to binge episodes, making it easier to diagnose.
Treatment for males can help them identify how they feel and connect with those feelings. They may not qualify what they’re feeling as distressful but also might not be able to describe feelings related to the binge eating disorder. Moreover, they might find nothing wrong with the episode, so the work may involve first identifying it as a problem.
All athletes, including male athletes, are at an increased risk for eating disorders. An estimated 33% of male athletes are affected by eating disorders.5 Sports with particular risk involve weight-class sports like wrestling and rowing, lean sports like cross country, and aesthetic sports like gymnastics, swimming, and diving.
Athletes face unique risks that non-athletes do not, such as:
Males are more likely to engage in disordered eating behaviors to develop greater muscularity. Much like girls and women receiving the message that they should strive for a “thin” ideal, men receive messaging from a young age that the “ideal” male body is muscular.
Up to 60% of boys in the U.S. report purposely manipulating their diet to increase their muscularity.1
Moreover, 90% of college-aged American males report a desire for greater muscularity.6 Boys as young as six prefer muscular body types.7
Men with muscle dysmorphia have a core belief and fear around insufficient muscularity and a pathological pursuit of muscularity. No matter how lean or muscular they get, they are convinced it is not good enough, they don’t look good enough, they aren’t big enough, etc.
This pathology in males can be similar to a woman’s pathological drive for thinness and cause many problems, severe preoccupation, distress, and impaired functioning.
Over several decades, evidence has accumulated in support of an association between sexual orientation and eating disorder symptoms in adults, particularly in men and adolescent males.
Gay males continue to report a higher prevalence of:1,3
Homosexual and bisexual boys report significantly greater body dissatisfaction than their heterosexual counterparts as well.1
At age 16, homosexual and bisexual boys had 12.5 times the likelihood of engaging in binge eating as heterosexual boys. In a study on Norwegian male adolescents, the researchers found that the boys with same-sex experiences were more likely to report bulimic symptoms than those without same-sex experiences, at about seven times the risk.1
Eating disorders can cause a host of medical complications in both men and women, many of which overlap, such as:8,9,10
However, there are many differences as well. Men with eating disorders are likely to experience lower testosterone levels and testicular volume.1 Males with anorexia may have an elevated risk for fracture, osteoporosis, and bone disease compared to female patients.11 What’s concerning is that loss of menstruation is part of the criteria to receive a bone scan to test for bone density and fracture risk, which means that boys and men get excluded from eating disorder best practices.
Regarding body composition, males with anorexia tend to have a lower percentage of extremity fat but not trunk fat than healthy boys. Adolescent boys with anorexia also have less severe fat deficits than adolescent girls with anorexia, which may cause medical professionals to underestimate the medical risk.12
The story is clear as day: boys and men must be included in every aspect of eating disorder care, from screening and diagnosis to referrals and treatment. One of the biggest improvements that needs to be made is tailoring screening and assessment tools to address how eating disorders present differently in boys and men.
One way to do this is to discuss body image issues concerning muscularity as opposed to thinness and to understand that excessive exercise can look like compulsive weight-lifting, too, not just cardiovascular exercises.
Treatment programs and treatment planning also need to address a broad spectrum of gender and sexuality presentations, including those who identify as transgender or gender fluid. And these treatment centers need to be accessible. Unfortunately, many current facilities with higher levels of care cannot admit boys given logistical issues around housing boys and girls separately, leading to further marginalization and internalization of stigma among young men seeking treatment.
Programs must solve these barriers to increase access to high-quality care and make everyone feel like they belong and are welcome.