Male Eating Disorders: What Do We Know and Where Do We Go Next?
Eating disorders (EDs) do not discriminate against age, ethnicity, sexual orientation, or even gender. While research on male eating disorders is scarce, findings consistently illustrate unique variants and differences in presentation and symptomatology. Thus, there is a critical need to understand the nuances between genders in order to better conceptualize, prevent, and treat, eating disorders adequately in males.
Eating disorders in males are not rare. While males may not present in high numbers for treatment, they do experience eating disorders, with differences in their presentation. For example, in anorexia nervosa, males often report different shape goals that are geared towards achieving leanness in the service of optimizing the visibility of muscularity, rather than a thin ideal per se. Adolescent males with anorexia nervosa are also more likely to express a desire to have a “six-pack” than a flat stomach. Males with bulimia nervosa also show differences in symptom presentation. Whereas females are more likely to binge on desserts, males are more likely to binge on high-protein and high fat foods such as meats, and are also less likely to report experiencing a loss of control or distress during a binge episode. Binge eating disorder in males has also shown that men may be less likely than women to be distressed about binge behavior. The more recent diagnosis of avoidant and restrictive food intake disorder has more limited research, given its relatively recent recognition as a formal diagnostic entity, although research suggests an increasing prevalence among males.
Given that there are differences in presentation across most of the eating disorders, it is important to understand how a preference for a more muscular body ideal with little body fat presents in males, as opposed to a thinner body ideal in females. Western cultural and societal depictions of male action figures and computer game characters are increasingly leaning towards dimensions of muscularity that are anatomically impossible in humans. The message of what an ideal male body should look like may be driving a wide range of muscularity-oriented body change behaviors in males. With regard to eating disorders, a muscularity-oriented body ideal may drive a distinct form of eating disorder behaviors in males that needs to be explored. In other words, relying on a traditional thinness-oriented framework for eating disorder pathology in males may be insufficient in accurately capturing muscularity-oriented forms of this pathology. One important factor to consider when observing eating disorders from the male perspective is the impact of the pathological pursuit of muscle density or definition known as muscle dysmorphia. Understanding this pathological pursuit of muscularity necessitates a greater focus on compulsive behaviors around exercise, dietary restriction, and compensatory behaviors as central primary illness feature. Sexual orientations within male eating disorders must also be taken into consideration as it may relate to cultural stereotypes and gender conformity.
In addition, research has identified a greater prevalence of ED among sexual minority males, alongside greater ED-related risk factors including objectification, drive for thinness, victimization, and co-occurring psychiatric conditions. However, with studies examining sexual orientation disparities in ED symptom profiles being generally underpowered, much greater research is needed in this area to better understand the intersectionality between sexual orientation, gender norms, and disordered eating psychopathology. Similarly, greater research is needed in delineating risk factors for ED psychopathology in transgendered populations, where an elevated prevalence has been noted.
So how can the field grow to best support males who struggle with EDs? This may be best answered by a three-pronged approach that addresses detection, intervention, and research with the overarching goal of destigmatization. First, the recognition of contributions from sociocultural frameworks, psychological pressures, and gender expression on males and masculinity. The misnomer of EDs being a “female disorder” are, thankfully, increasingly behind us. Improvements to accepted measures of ED symptomatology must be adapted to incorporate and validate the male experience (sensitivity to muscularity-oriented disordered eating and de-emphasis of thinness in feminine features). At present, empirical evidence suggests that males are more likely to be misdiagnosed when presenting at specialized treatment centers, leading to greater illness entrenchment and longer duration of disorder. Establishing medical, psychological, and psychiatric guidelines that are more inclusive to the male experience of EDs (testosterone impairment, steroid use, cardiovascular complications, bone density complications).
Second, clinical considerations for the treatment of males would benefit from fostering and adapting interventions that consider the male experience. Treatment specialists would gain from additional training in co-occuring disorders, specialized tracks that address male concerns, as well as milieu modifications that seek to eliminate male exclusivity (groups designed to discuss male body image issues, exercise and physical activity interventions, sexual orientation and attraction, as well as sexual performance issues).
Third, the marginalization of males in ED research is another opportunity for expansion and growth. Inconsistent with female counterparts, male ED research largely finds discrepancies or lack of representation within age, culture, ethnicity, psychometric indices and neurobiology, as well as pathophysiology. Evidence currently suggests that men within middle ages of adulthood struggle with negative body talk. Furthermore, non-white males have increased weight related concerns/behaviors and increased engagement with extreme weight-loss strategies. To date, there has yet to be a neuroimaging study inclusive of male subjects, thus excluding male considerations from treatment suggestions and newly developed interventions.
Certainly, the prevalence of males with EDs is growing, with that our classification, assessment, treatment, and research should as well. The understanding of EDs in males and mental health literacy can improve individuals affected, increase quality of care, and diminish barriers for seeking treatment.
Dr. Marissa Corona is a Clinical Assistant Professor in the Department of Psychiatry and the Behavioral Sciences at the University of Southern California. She specializes in evidenced-based psychological treatments for adolescents and young adults with eating and feeding disorders.
Dr. Dani Gonzales licensed clinical psychologist and full-time faculty member specializing in the treatment of Eating Disorders within the Department of Psychiatry at the University of Southern California’s Keck School of Medicine. Dr. Gonzales currently maintains a small private practice in Southern California that offers evidenced-based treatment for young adults, males struggling with Eating Disorders, Elite and Professional Athletes, and individuals struggling with addiction.
Dr. Murray is an Associate Professor and Director of the Eating Disorders Program in the Department of Psychiatry & Behavioral Sciences at the University of Southern California. His program of research focuses on identifying the mechanisms underpinning eating disorder psychopathology and the development of novel treatments.
