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Macho, Bravado, and Eating Disorders in Men: Special Issues in Diagnosis and Treatment

Macho, Bravado, and Eating Disorders in Men: Special Issues in Diagnosis and Treatment

The treatment process for patients with eating disordersTreatment Process
Recently, we met with J. As the teenager walked into our office for the first meeting, J’s thin, frail 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 in the shower drain. In that first meeting, J described being plagued by worries and a brutal exercise regimen coupled with a diet highly 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 we told 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 following week, he confided, through his tears, that he always thought that only “emotional teenage girls” had 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 and the stigma and shame associated with that possibility are important ones.

Technology and the rise of the Internet have added new complexities. In recent years, pro–eating disorder websites have emerged as a platform through with individuals with eating disorders may share 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 tips and tricks to promote starvation and weight loss, images of emaciated figures, and inspirational quotes (so-called “thinspiration”), as well as chat rooms that allow users to interact with one another.1

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 has frequently been stated that 10% of individuals with eating disorders 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.2 In fact, the best available data indicate that males account for 25% of individuals with anorexia nervosa and bulimia nervosa and 36% of those with binge eating disorder.3 Most disturbingly, disordered eating practices may, for the first time, be increasing at a faster rate in males than in females.4 Unfortunately, research has not kept pace with the prevalence of eating disorders in males. In a meta-analysis of 32 prevention studies, only 4 (12.5%) included boys.5 Most empirical studies simply do not include males.

The treatment process for patients with eating disorders can be divided into 4 stages (for an in-depth discussion of each of these stages, see Wooldridge6):


Engagement falters for 2 reasons. First, many males 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 urgent medical treatment is needed. 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.7 Moreover, research shows that males are more likely to seek treatment at an older age than their female counterparts.8

Advocacy work that includes males is an essential task for both researchers and clinicians. The National Association for Males With Eating Disorders has recently been revitalized and is now a thriving organization that aims to provide leadership in the field of male eating disorders. Other organizations, such as the National Eating Disorders Association, are increasingly acknowledging the prevalence of male patients.


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