Recent research has shown a higher incidence of men with eating disorders than previously thought. How do men with eating disorders differ from women in terms of assessment and treatment? What are the differences in risk factors and possible comorbidities, if any?
The occurrence of eating disorders in men remains relatively rare but consistent. This is true despite recent research suggesting that male cases are far more numerous than had been previously thought. This brief article will comment on recent research findings in this area and describe their relevance to assessment and treatment.
Two studies support the notion that eating disorders are more common than had previously been thought (Health Canada, 2003; Woodside et al., 2001). Woodside et al. (2001) reported on the results of a 10,000-person community epidemiologic study. Combining full- and partial-syndrome eating disorder cases for both men and women, the investigators showed an overall rate of three female cases for every one male case-a far cry from the typical 10:1 or 20:1 ratio found in most treatment settings. However, this study assessed only limited Axis II parameters and, as DSM-III-R diagnoses were generated from the data, the prevalence of binge-eating disorder could not be assessed.
More recently, Health Canada (2003) released preliminary results from a national, face-to-face mental health survey of over 30,000 people performed in 2001 and 2002. This survey assessed for full-syndrome eating disorders and reported a ratio of male to female cases of approximately 1:5. This was somewhat higher than the findings from Woodside et al. (2001) but showed many more cases than might otherwise have been thought. The somewhat higher ratio in the Health Canada survey is almost certainly related to only full-syndrome cases that the Woodside et al. survey was too small to allow for.
Nature of the Illness
Studies continue to show that the nature of the illness, when it occurs in men, is essentially indistinguishable from women. In Woodside et al. (2001), the sample of male eating disorder cases in the community was compared to female eating disorder cases in the same sample and a sample of 3,769 unaffected males. There were no significant differences in any variables relating to illness severity. As mentioned, both full- and partial-syndrome cases were included. Previous research showed that partial-syndrome cases did not differ from full-syndrome cases on most eating disorder variables; there was an excess of partial-syndrome cases of bulimia nervosa in males compared to females. This may have been an artifact of the small sample size in the study.
Other studies have examined differences in personality between men and women with eating disorders (Fassino et al., 2001; Woodside et al., submitted for publication). These studies demonstrated that men with eating disorders had lower scores on the Temperament and Character Inventory (TCI) for Harm Avoidance, Reward Dependence and Cooperativeness. Our study also showed lower perfectionism in male cases.
Response to Treatment
There is an extreme scarcity of literature regarding differential response to treatment in men with eating disorders compared to women. The literature that does exist suggests that men and women receive similar benefit from treatment for their eating disorder (Woodside and Kaplan, 1994). This is an area that deserves much more attention.
We are thus left with a confusing situation: Men appear to suffer from eating disorders with a higher frequency than would be thought, based on data obtained from clinical settings, despite having a similar illness and similar responses to treatment. What could explain these findings and what impact might such explanations have for practicing clinicians?
Why are fewer affected men identified in formal treatment settings? One possible explanation is that men simply do not see themselves as being at risk, and therefore dismiss or ignore symptoms that might be indicative of an illness requiring treatment. For example, a young woman who is overeating and vomiting would be quite likely to self-identify as having bulimia nervosa, due to the large amount of public attention that has been paid to these conditions. A young man with similar symptoms might simply think that his eating habits are bad or that he drinks too much, not paying too much attention otherwise. Friends-both male and female-might also have a lower index of suspicion for a formal eating disorder and attribute symptoms to other causes.
A young man who is losing weight might be identified as having a drug problem or AIDS, rather than suffering from anorexia nervosa. Again, neither male nor female friends might make the connection between the outward symptom and the presence of an illness, simply because of the societal expectation that individuals with eating disorders are all female.
The relevant message for clinicians is to be aware that men are at risk for eating disorders and to include a history of eating-related behaviors in their exams. This is particularly important in the identification of bulimia nervosa, which may have no outward symptoms.
Men may also be worried about assumptions about sexual orientation. There is a long controversy about the extent to which homosexual men might be over-represented among those males with eating disorders. To date, all the research done on this question has been in clinical samples and may be biased. Studies from these clinical populations have cited high rates of homosexual orientation (Herzog et al., 1984). Unfortunately, information on sexual orientation was not available for the Woodward et al. (2001) study. We are attempting to discover whether this information is available for the Health Canada (2003) study. Thus, there is no definitive answer to the question of sexual orientation and eating disorders.
One idea that has been raised to explain these findings is that homosexual men may be less reluctant to self-identify as suffering from an eating disorder because of the different focus on weight and shape in the homosexual male community. They may also simply be more willing to access treatment once they have identified their behaviors as troublesome. For the clinician, the most important issue to remember is to reassure heterosexual male patients that the diagnosis of an eating disorder does not require any specific sexual orientation and that no assumptions will be made about sexual orientation, one way or the other.
Men may be unwilling to enter treatment programs that are mainly for women. There is a fairly good awareness among both men and women about the extent to which eating disorders are a problem for women, which includes the idea that all available treatment programs are for women only. Alternately, men may experience a general reduction in help-seeking behaviors that is independent of diagnosis. I am unaware of any treatment programs specifically for men, aside from an occasional support group. Unfortunately, the lack of male-specific treatment programs reinforces the idea that treatment is only for women.
I am equally unaware of significant programs that exclude men. The reduced focus on treatment of men is usually related to the small number of men presenting for treatment--so a circular arrangement occurs. While there is little formal research on treatment outcome for men, most senior clinicians will indicate that the outcome appears to be similar for both men and women. I tell prospective male patients that the usual role a male patient ends up taking in a treatment group is that of a brother--someone the female patients trust and feel close to, but with whom there are clear boundaries. In my treatment programs, men are included in all aspects of the program when admitted. In fact, our female patients have told us that they appreciated having a male peer's input on issues pertaining to relationships, appearance and so forth.
For the clinician, the most important messages for male patients are that the treatment is the same for men and women and that men are generally welcomed, both by the treatment team and by other members of the treatment group. It is worth reassuring a male patient that he is likely to be accepted by the group and will find a comfortable place there.
Are there any differences in the treatment a male patient should receive? Generally, the answer to this question is no. Men respond to the same types of interventions as do women, to the best of our knowledge. There is sometimes a perception that men who are affected have more severe illness. This is probably due to the fact that when large numbers of male patients are compared to female patients, there are no significant differences.
Clinicians will of course be aware that men and women are socialized differently in Western culture, and while the overall process of eating disorder cognitions is the same, the precise content may be slightly different. For example, men are more involved in competitive sports and thus will talk more about their concerns about athletic prowess.
It is important to remember that while rates of sexual abuse are lower in men than in women, that about 10% of men with an eating disorder reported a history of sexual abuse (Woodside et al., 2001). As is the case with women, such an occurrence may be an important factor in the etiology of the eating disorder.
The occurrence of eating disorders in men appears to be more common in the community than had previously been thought. There are a number of factors that may keep men out of treatment, ranging from lack of self-identification to perceived stigma. Once in treatment, men appear to respond in much the same way as do women.
Fassino S, Abbate-Daga G, Leombruni P et al. (2001), Temperament and character in Italian men with anorexia nervosa: a controlled study with the temperament and character inventory. J Nerv Ment Dis 189(11):788-794.
Health Canada (2003), Canadian Community Health Survey. Ottawa, Ontario: Statistics Canada.
Herzog DB, Norman DK, Gordon C, Pepose M (1984), Sexual conflict and eating disorders in 27 males. Am J Psychiatry 141(8):989-990.
Woodside DB, Bulik CM, Thornton L et al. (submitted for publication), Personality in men with eating disorders. J Psychosom Res.
Woodside DB, Garfinkel PE, Lin E et al. (2001), Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. Am J Psychiatry 158(4):570-574.
Woodside DB, Kaplan AS (1994), Day hospital treatment in males with eating disorders-response and comparison to females. J Psychosom Res 38(5):471-475.