Males conservatively make up approximate-ly 10% of anorexia nervosa and bulimia nervosa patients (bulimia nervosa is the more common disorder). The typical age range at presentation is adolescence to young adulthood.1 However, for binge eating disorder, rates for males are comparable to those for females, and at presentation, patients are typically adults. Binge eating disorder is often associated with obesity and the medical consequences of weight gain.2
While the acute presentations of anorexia nervosa and bulimia nervosa in males and females tend to be the same and include weight loss and malnutrition and/or binge eating with compensatory behaviors, such as self-induced vomiting and calorie restriction, there are significant clinical differences between males and females who have eating disorders. Because of the growing awareness of males with eating disorders, this article addresses the similarities and differences between male and female risk factors, clinical presentations, and treatment.
The cause of eating disorders is multifactorial and typically manifests as idealizing dieting and weight loss. However, there are characteristics that are predictive of high risk for eating disorders in males.
Exercise and athletic competition, especially sports that require low body fat or extremes of weight loss, represent risks for disordered eating. A Norwegian study of elite athletes found that the rates of eating disorders in males were twice those of the general male population. For males who participate in antigravitation sports, such as high-jumping and pole-vaulting, the rates are particularly increased.3 The risk of eating disorders among triathletes also seems to be increased, as determined by increased scores on tests for abnormal eating.4 At least one study in male cyclists found that perfectionism may predict an increased likelihood of disordered eating.5
Not only are rates of eating disorder diagnoses higher in homosexual men than in heterosexual men, but also scores on ratings of eating psychopathology and body image concerns, media influence, and body image–related anxiety are higher.6,7 Evidence suggests that younger, heavier gay men are at increased risk for eating disorders.8 Sexual identity disorders may also increase the risk of eating disorders.9,10 In addition, gay males experience higher levels of peer pressure to maintain a particular body type than do straight males, and higher levels of body dissatisfaction may account for higher levels of disordered eating.11
Males who present for treatment are much more likely than females to have been subjected to weight-based victimization and to have a history of being overweight.12 Other factors that may increase the risk of an eating disorder in males include alcoholism and physical abuse.13-16
In patients with eating disorders, there are high rates of chemical dependency, depression, and anxiety disorders. A large Canadian study of a nonclinical sample found that women who scored high on an eating disorder self-report measure were about 3 times as likely to have a comorbid substance use disorder, while men were about 2 times as likely.17,18 Both males and females often use drugs of abuse that have appetite suppressant characteristics. Typically, this involves the use of cocaine or other illicit and prescription stimulants to reduce appetite and facilitate restrictive eating.19 Compared with the general population, men with eating disorders have been found to be 4.6 times more likely to suffer from an anxiety disorder, and women, 4.2 times more likely.18
What is already known about males with eating disorders?
? Similar to females, males are at risk for psychological and metabolic consequences of eating disorders—including increased rates of depression, anxiety disorders, and addictive disorders, as well as osteoporosis.
What new information does this article provide?
? The article focuses on eating disorders in males and presents information on similarities and differences between males and females as they relate to risk factors, clinical presentation, and treatment.
What are the implications for psychiatric practice?
? A treatment approach that emphasizes normalized nutrition and eating behaviors and that includes cognitive-behavioral therapy is effective in helping males recover from an eating disorder. To optimize treatment response, it is often necessary to address the issue of excessive exercise as a symptom of an eating disorder.
Not surprisingly, evidence indicates that men are as concerned about body image as women.19 However, unlike women whose preferred body image is thin, men’s preferred body image is muscular. Factors that contribute to an abnormal desired, or “idealized,” body and body image distortion in males include the media, cultural changes leading to unrealistic expectation of body image and muscularity, and body building.20-22
In developing the Swansea Muscularity Attitudes Questionnaire, a study was designed to investigate men’s concerns about muscularity. The results suggest that men engage in activities that increase their muscularity because they perceive muscularity will enhance their feelings of masculinity and confidence while improving their attractiveness.
In an experimental study, a computerized body image assessment was used in 27 men with an eating disorder (17 with anorexia nervosa, 10 with bulimia nervosa), 21 men who were athletic, and 21 nonathletic age-matched controls.23 The test allowed participants to “morph” a computer image using 10 levels of muscularity and body fat to depict 4 body types: the participant’s own body, his ideal body, the body of an average man in his age-group, and the body image women would prefer. While there were few differences on the muscularity indices, there were significant differences in the body fat indices, wherein the men with anorexia nervosa and bulimia nervosa perceived themselves as almost twice as fat as they actually were.
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