Macho, Bravado, and Eating Disorders in Men: Special Issues in Diagnosis and TreatmentPublished on Physicians Practice (http://www.physicianspractice.com)

Macho, Bravado, and Eating Disorders in Men: Special Issues inDiagnosis and TreatmentMay 26, 2016By Tom Wooldridge, PsyD [1] and Ray Lemberg, PhD [2]

Eating disorders are still thought of as a “female problem.” But 25% of those with anorexia and 36%of those with bulimia are males.

THE CASERecently, we met with J. As the teenager walked into our office for the first meeting, J’sthin, frail body and eyes surrounded by dark circles spoke volumes. The family had decided to speakwith a mental health provider after J’s mother found her child’s hair in the shower drain. In that firstmeeting, J described being plagued by worries and a brutal exercise regimen coupled with a diethighly restrictive in both calories and variety intended to assuage a fear of being “too fat.”

In many ways, this is a run-of-the-mill description of a patient with an eating disorder. But what if wetold you that J’s full name is Josh and that he is a 14-year-old boy?You may not be surprised, but Josh’s father was. When he came in to meet with us the followingweek, he confided, through his tears, that he always thought that only “emotional teenage girls” hadanorexia nervosa. While a number of complex factors prevented the family from seeking treatmentearlier, the belief that men and boys do not suffer from eating disorders and the stigma and shameassociated with that possibility are important ones.Technology and the rise of the Internet have added new complexities. In recent years, pro–eatingdisorder websites have emerged as a platform through with individuals with eating disorders mayshare and encourage an array of eating-disordered behaviors. For example, pro-anorexia (pro-ana)forums operate on the premise that eating disorders are a “lifestyle choice” and often feature tipsand tricks to promote starvation and weight loss, images of emaciated figures, and inspirationalquotes (so-called “thinspiration”), as well as chat rooms that allow users to interact with oneanother.1Eating disorders are often thought of as a “female problem.” Even researchers, advocates, andtreatment providers who are aware that these disorders affect men and boys are plagued bymisinformation. For example, it has frequently been stated that 10% of individuals with eatingdisorders are male. As it turns out, this often-repeated statistic is highly problematic. When it waspublished 25 years ago, it represented the number of men and boys in treatment, not in the generalpopulation.2 In fact, the best available data indicate that males account for 25% of individuals withanorexia nervosa and bulimia nervosa and 36% of those with binge eating disorder.3 Mostdisturbingly, disordered eating practices may, for the first time, be increasing at a faster rate inmales than in females.4 Unfortunately, research has not kept pace with the prevalence of eatingdisorders in males. In a meta-analysis of 32 prevention studies, only 4 (12.5%) included boys.5 Mostempirical studies simply do not include males.The treatment process for patients with eating disorders can be divided into 4 stages (for an in-depthdiscussion of each of these stages, see Wooldridge6):EngagementEngagement falters for 2 reasons. First, many males fail to recognize that their behavior (weightloss, purging, binge eating, compulsive exercise, etc) is a symptom of an eating disorder. And whenthey do recognize this, their help-seeking behavior is often hindered by stigma and shame. All toooften, friends, family, and medical providers fail to recognize that urgent medical treatment isneeded. In one study, male patients with anorexia nervosa emphasized the lack ofgender-appropriate information and resources for men as an impediment to seeking treatment.7Moreover, research shows that males are more likely to seek treatment at an older age than theirfemale counterparts.8Advocacy work that includes males is an essential task for both researchers and clinicians. TheNational Association for Males With Eating Disorders has recently been revitalized and is now athriving organization that aims to provide leadership in the field of male eating disorders. Other

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Macho, Bravado, and Eating Disorders in Men: Special Issues in Diagnosis and TreatmentPublished on Physicians Practice (http://www.physicianspractice.com)

organizations, such as the National Eating Disorders Association, are increasingly acknowledging theprevalence of male patients.There are obstacles to the alliance-building process that are specific to men and boys with eatingdisorders. Stigma and shame often make the alliance-building process more difficult and should beaddressed early in treatment. Stigma must be named and the layers of shame and embarrassmentbeneath acknowledged.Traditional constructs of masculinity make the alliance-building more difficult. Men appear to holdmore negative attitudes toward mental health treatment than women.9 The effort to conform toperceived socially prescribed gender roles prevents the expression of vulnerability and need forhelp.10 Keeping this in mind, intervention should target normative beliefs (ie, that other males don’tseek treatment), which are deeply related to the male experience of stigma and, thus, help-seekingbehavior.11

Assessment and diagnosisDifferent approaches may be employed during the assessment process, ranging from anunstructured interview to a structured diagnostic interview. At present, the most commonly usedformal measures of eating disorder symptomatology appear to be less applicable to males. Forexample, males consistently score lower than females even when their levels of psychopathology areequivalent. In addition, the measures appear to be less internally reliable among males.12 With theseconcerns in mind, a number of assessments are currently being adapted and validated for malepopulations.Two diagnoses deserve special mention in male populations. First, muscle dysmorphia, asub-classification of body dysmorphia, has gained attention in recent years. The distinguishingfeature of muscle dysmorphia is the central role of muscularity-oriented, as opposed tothinness-oriented, body image concerns and behaviors.13 This disorder is characterized by an intensefear that one is insufficiently muscular and an excessive drive to enhance the visible appearance ofmuscularity. Patients with muscle dysmorphia work out and lift weights excessively, and theyexperience extreme anxiety in the face of missed workouts.14

Second, binge eating disorder, is the most common eating disorder and affects more males thananorexia and bulimia combined. Binge eating disorder is characterized by episodes of bingeing andsubsequent shame and guilt, after which the cycle repeats. All too often, health professionalsaddress comorbid symptoms, which include diabetes, high blood pressure and cholesterol, heartdisease, gallbladder disease, osteoarthritis, and gastrointestinal problems, without recognizing andtreating the underlying eating disorder.15 Similarly, because of misinformation and stigma, menoften think of binge eating as “normal guy” behavior.While eating disorders in males exist across ages and cultures, certain populations deserve specificmention. Males who identify as gay, bisexual, and transgender are at higher risk for an eatingdisorder.16 The most widespread explanation for the increased incidence of eating disorders in thehomosexual population is that gay men experience more body dissatisfaction than heterosexualmen.17 Indeed, the lean and muscular body type, which is difficult to achieve for most, is especiallyidealized by gay men.The transgender population merits further investigation as an especially high-risk category. In arecent study of college-aged youth, an eating disorder diagnosis as well as diet pill and laxative useand vomiting was most common among transgender youth compared with heterosexual andhomosexual men and women.18

Athletes are also at increased risk for eating disorders. Men and boys in a wide range of sports suchas wrestling, boxing, racing, gymnastics, and cross country may lose weight by purging, fasting, andover-exercising. Similarly, many crew athletes go on “sweat runs,” wearing multiple layers ofclothing while running in hot weather.19 Bodybuilders are especially likely to have muscledysmorphia. Coaches play an important role in the effect sports have on male participants. Indeed,coaches can either promote eating disorders among athletes or be partners in treatment, promotingfull recovery instead of merely a return to sports participation.20

TreatmentA multidisciplinary and integrative treatment approach is required to fully address all the factors thatcontribute to the patient’s eating disorder. Unsurprisingly, better outcomes are achieved with anexperienced multidisciplinary team rather than a single clinician.21

Treatment teams often consist of psychologists, psychiatrists, social workers, primary carephysicians, registered dieticians, and sometimes educators, clergy, and even financial advisors tofacilitate expensive inpatient treatment. In a similar vein, in an effort to address the complexity of

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Macho, Bravado, and Eating Disorders in Men: Special Issues in Diagnosis and TreatmentPublished on Physicians Practice (http://www.physicianspractice.com)

the patient system, treatment should be integrative and include systemic, biological, cultural,psychodynamic, and spiritual domains.6This emphasis on integrative treatment often stands in contrast with the emphasis onsymptom-focused treatments that, while valuable, may fail to acknowledge the underlying roots of apatient’s struggles. Similarly, much has been made of the role of genetic vulnerability in patientswith eating disorders. One compelling line of research suggests that the genetic vulnerability rangesfrom 50% to 70%. Indeed, monozygotic twins share a 50% chance of having an eating disorder if oneis afflicted.22 At present, however, there is no consensus on what causes genetic vulnerability.Too much emphasis on genetic factors may impede the treatment process. By focusing on genetics,clinicians may overlook the role of factors such as underlying anxiety; depression; dysfunction withinfamily systems; or psychodynamic meanings associated with food, weight, and shape, which can beaddressed in treatment.ConclusionWe are just beginning to understand how online media affects men and boys struggling with eatingdisorders ranging from anorexia nervosa to muscle dysmorphia. Mass media, in general, appears tohave placed increasing pressure on males to pursue an unrealistic body image of thinness and/ormuscularity.23THE CASE (cont'd)In closing, let’s return to Josh. The initial stages of treatmentconsisted of educating Josh and his family about the fact that eating disorders don’t happen only toadolescent 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 werean integral component of the treatment team as well, essential to the process of helping him tonormalize 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 treatmentfor his attitudes toward food, weight, and shape to fully normalize, Josh eventually achieved fullrecovery.

Treatment Process Disclosures: Dr Wooldridge is Department Chair and Assistant Professor in the department of psychiatry atGolden Gate University in San Francisco. Dr Lemberg is a licensed psychologist in private practice inPrescott, Arizona. The authors report no conflicts concerning the subject matter of this article. References: 1. Bardone-Cone AM, Cass KM. What does viewing a pro-anorexia website do? An experimentalexamination of website exposure and moderating effects. Int J Eat Disord. 2007;40:537-548.

2. Andersen A. Males and Eating Disorders. New York: Brunner/Mazel; 1990.

3. Hudson J, Hiripi E, Pope H, Kessler R. The prevalence and correlates of eating disorders in thenational comorbidity survey replication. Biol Psychiatry. 2007;61:348-358.

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Macho, Bravado, and Eating Disorders in Men: Special Issues in Diagnosis and TreatmentPublished on Physicians Practice (http://www.physicianspractice.com)

4. Mitchison D, Hay PJ. The epidemiology of eating disorders: genetic, environmental, and societalfactors. Clin Epidemiol. 2014;6:89-97.

5. Stice E. Risk and maintenance factors for eating pathology: a meta-analytic review. Psychol Bull.2002;128:825-848.

6. Wooldridge T. Understanding Anorexia Nervosa in Males: An Integrative Approach. New York:Routledge; 2016.

7. Räisänen U, Hunt K. The role of gendered constructions of eating disorders in delayedhelp-seeking in men: a qualitative interview study. BMJ Open. 2014.http://www.west-info.eu/poor-treatment-for-men-with-eating-disorders/bmj-open-2014-raisanen/.Accessed March 24, 2016.

8. Gueguen J, Godart N, Chambry J, et al. Severe anorexia nervosa in men: comparison with severeAN in women and analysis of mortality. Int J Eat Disord. 2012;45:537-545.

9. Andrews G, Issakidis C, Carter G. Shortfall in mental health service utilisation. Br J Psychiatry.2001;179:417-425.

10. Galdas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: literature review. JAdv Nurs. 2005;49:616-623.

11. Hammer J, Vogel D, Heimerdinger-Edwards S. Men’s help seeking: examination of differencesacross community size, education, and income. Psychol Men Mascul. 2013;14:65-75.

12. Darcy AM, Lin IH. Are we asking the right questions? A review of assessment of males witheating disorders. Eat Disord. 2012;20:416-426.

13. Murray SB, Rieger E, Touyz SW, De la Garza Garcia Y. Muscle dysmorphia and the DSM-Vconundrum: where does it belong? Int J Eat Disord. 2010;43:483-491.

14. Murray SB, Griffiths S, Hazery L, et al. Go big or go home: a thematic content analysis ofpro-muscularity websites. Body Image. 2016;16:17-20.

15. Bulik CM, Reichborn-Kjennerud T. Medical morbidity in binge eating disorder. Int J Eat Disord.2003;34(suppl):S39-S46.

16. Brown TA, Keel PK. The impact of relationships on the association between sexual orientationand disordered eating in men. Int J Eat Disord. 2012;45:792-799.

17. Andersen AE, Cohn L, Holbrook T. Making Weight: Healing Men’s Conflicts With Food, Weight,and Shape. Carlsbad, CA: Gürze Books; 2000.

18. Diemer EW, Grant JD, Munn-Chernoff MA, et al. Gender identity, sexual orientation, andeating-related pathology in a national sample of college students. J Adolesc Health. 2015;57:144-149.

19. Baum A. Eating disorders in the male athlete. Sports Med. 2006;36:1-6.

20. Mehler PS, Andersen AE. Eating Disorders: A Guide to Medical Care and Complications.Baltimore, MD: Johns Hopkins University Press; 1999.

21. Halmi KA. Anorexia nervosa: an increasing problem in children and adolescents. Dialogues ClinNeurosci. 2009;11:100-103.

22. Bulik CM, Sullivan PF, Tozzi F, et al. Prevalence, heritability, and prospective risk factors foranorexia nervosa. Arch Gen Psychiatry. 2006;63:305-312.

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Macho, Bravado, and Eating Disorders in Men: Special Issues in Diagnosis and TreatmentPublished on Physicians Practice (http://www.physicianspractice.com)

23. Santa Cruz J. Body image pressure increasingly affects boys. The Atlantic. March 10, 2014. http://www.theatlantic.com/health/archive/2014/03/body-image-pressure-increasingly-affects-boys/283897/. Accessed March 24, 2016. Source URL: http://www.physicianspractice.com/special-reports/macho-bravado-and-eating-disorders-men-special-issues-diagnosis-and-treatment

Links:[1] http://www.physicianspractice.com/authors/tom-wooldridge-psyd[2] http://www.physicianspractice.com/authors/ray-lemberg-phd

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