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
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.
More than half of the men present-ing for eating disorder treatment at Rogers Memorial Hospital report problematic exercise behaviors. Men are more susceptible than women to elements of excessive exercise, such as a lack of control, increased tolerance, and reduction in alternative activities.24
Signs of excessive exercise include highly structured and repetitive exercise routines that tend to focus more on endurance activities—most commonly, running. Patients will often engage in exercise rather than spend time with family or attend school or work. Furthermore, these patients continue to engage in exercise even when injured or despite being underweight, and they experience increased emotional distress when exercise is limited. Also, excessive exercising tends to occur in isolation, with a tendency to exercise alone or in secret.
Exercise, body image, and weight loss
The relationship between body image and exercise is not destructive if a well-balanced approach to health and personal growth is used. However, in men who do not have a well-balanced approach, there are 2 factors that may increase their risk for an eating disorder. First, they reduce food intake incrementally over time, to the point of very low calorie intake and avoidance of fats and often carbohydrates. Second, exercise activities are not aimed at maintaining strength and muscle mass; rather, there is an increase in time spent in calorie-burning activities. Both activities will accelerate inadequate nutritional intake and weight loss in patients with anorexia nervosa and appetite dyscontrol or patients with binge eating and purging with bulimia nervosa. The focus on body image and muscle definition is achieved through reduced body fat rather than increased muscle mass. Attempts at increasing food intake, and the associated fears of increasing body fat, can trigger exercise behaviors or purging.
Evaluation and treatment
Several studies suggest that men and women have a similar response to treatment.25-27 In general, treatment for males with eating disorders focuses on 3 important factors:
• Setting nutritional goals aimed at normalizing weight (and therefore normalizing physiology and partially reversing physiological changes associated with weight loss), normalizing food intake, reducing the number of feared foods, and reducing behaviors to compensate for eating or fear of weight gain.
• Identifying and challenging errors in thinking about food, weight, and shape using CBT.
• Identifying obstacles to recovery that ideally should be addressed to improve treatment response and ultimately increase the chances of full recovery.These can be grouped together and include other co-occurring Axis I psychiatric conditions, such as affective, anxiety, or substance abuse disorders; adverse treatment experiences; and traumatic experiences, such as sexual abuse or weight-based victimization.
Weight restoration. Nutritional intervention for males with anorexia nervosa involves stopping weight loss, restoring weight, and normalizing eating behavior. The information available to guide us in determining what is normal weight or a weight that maximizes the chances of recovery from anorexia nervosa is greater for females than for males.28 For females, guidelines for determining body weight for recovery include return of normal menstrual function. For underweight male patients, who are susceptible to hypothalamic hypogonadism and osteoporosis, measurements of serum testosterone levels can be imprecise but helpful in assessing nutritional status. Study findings indicate that patient education concerning the negative impact of malnutrition on physical health can be effective in challenging eating disorder beliefs and facilitating treatment progress.29 An adequate weight history, adolescent growth charts, and family characteristics, can also be helpful.
Ideally, the amount of weight gain should be determined by a medical or dietary professional experienced with eating disorders. During the weight gain phase, patients should be strongly encouraged to significantly limit or refrain from excessive physical activity. Anxiety during weight gain should be redirected toward working on self-esteem and coping skills, as well as exploring antecedents of the eating disorder that often relate to body weight, such as teasing or bullying.
Males tend to overvalue muscularity in terms of body image and therefore are much more concerned about building muscle with weight gain and are fearful of body fat, whereas females are more fearful of any type of weight gain or increase in size. Males also tend to be more fearful of fats and carbohydrates in food compared with females who are more calorie-avoidant in general. It is also important to address dietary behaviors that are very rigid and limited in terms of food varieties because these typically are related to resistance to eating normally and decreased treatment effectiveness.
CBT. On the basis of clinical experience, CBT appears to be a very useful treatment for males with eating disorders. CBT gives patients a framework with which to work on eating disorder symptoms as well as on anxiety and affective disorders. In addition, CBT helps identify and challenge errors in thinking concerning food, weight, body image, and the drive to exercise, along with the many different triggers, thoughts, and feelings associated with eating disorder behaviors.
Males with eating disorders tend to externalize emotional distress and, in general, are less likely to be comfortable talking about their feelings, negative experiences, or life events. CBT provides an understandable and structured approach that both addresses externalizing tendencies and facilitates a positive exploration of thoughts and feelings.
For males, as for females, the average length of time between onset of illness and treatment is approximately 5 years.30 Patients often report feeling forced into treatment. Engaging the male patient in treatment can be facilitated using all-male treatment groups. In these groups, males see other males discussing eating disorder symptoms that typically have been viewed as “female” problems, and they experience appropriate emotional expression that is identified as strength rather than weakness.
Because of the increased likelihood of externalized coping skills and anger as a symptom of depression, a treatment team member’s ability to be comfortable with the male population can facilitate expression of thoughts and feelings as an alternative to less helpful coping skills. Family therapy is essential to allow for appropriate and productive emotional expression and healthy conflict for patients, rather than using eating disorder behaviors as the main mechanism for emotional regulation. Experiential therapy programs that include art therapy, movement, and recreation therapy are particularly useful for work on body image and healthy nonverbal expression, team building, problem solving, and exercise issues.
Approach to excessive exercise. As part of treatment, excessive exercise behaviors often need to be addressed. Ideally, therapy should be individualized for the patient on the basis of fitness beliefs and behav-iors. Obtaining collateral information from parents, former medical and behavioral health care providers, and coaches is recommended because patients typically minimize these behaviors and are often reluctant to identify exercise behaviors as dysfunctional.
For treatment of underweight persons, all but the most quiescent fitness activities are suspended until weight restoration is progressing satisfactorily. Once there is a positive response to nutritional and other components of treatment, fitness activities are introduced slowly and re-sponses are observed closely. This is difficult for many persons with eating disorders at this level of care, but particularly so for athletes or those who identify closely with athletics.
Men with an eating disorder who present for treatment with exercise concerns generally fall into 3 groups. First, there are those who use exercise behaviors in an addictive fashion as mood enhancement. These patients report a history of behaviors such as lying about their exercise to family and friends and using exercise to avoid difficult emotions. When exercise is discontinued in a structured treatment environment, patients exhibit moderate to severe symptoms of irritability and sometimes an increase in depression. These patients benefit from exploring the source of their dedication and how it has led to disordered eating.
A second cluster of patients are compulsive exercisers. They have highly ritualized exercise behaviors that result in anxiety when disrupted. These patients often have co-occurring obsessive-compulsive symptoms not related to exercise. Such patients are treated with exposure and ritual prevention as well as experiential therapy.
Finally, the third group is made up of patients whose lives have simply become out of balance with a dedication to fitness and athletics in conjunction with problematic eating. Similar to the first group, these patients also benefit from exploring the source of their dedication and how it has led to disordered eating.
It is likely that rates of eating disorders in males will continue to increase.31While differences exist in risk factors and symptom expression in males with eating disorders, a growing body of evidence suggests that males respond well to treatment. However, treatment needs to be individualized for the male patient, ideally in a setting with other males and with staff experienced in working with males. Obstacles to treatment include a lack of awareness that males are at risk for eating disorders and male perception that having an eating disorder is very stigmatizing.28,32
References1. Carlat DJ, Camargo CA Jr, Herzog DB. Eating disorders in males: a report on 135 patients. Am J Psychiatry. 1997;154:1127-1132.