Eating Disorders in Males

Eating disorders have been observed in males since 1689, when Dr. Richard Morton described the first documented case of anorexia nervosa in a young man. Two cases of males were also reported in the first description of bulimia nervosa by Prof. Gerald Russell in 1979. However, the research on eating disorders has been traditionally focused on females.

Only recently, researchers have recognized that males show distinctive body image and eating concerns with a greater drive for muscularity and use of specific muscle-enhancing behaviors, such as diets, supplement use, and androgenic-anabolic steroid use to build muscle. These specific attitudes and behaviors may lead to eating disorders in extreme cases and require an adaptation of the traditional treatments of eating disorders.

Some Data on the Prevalence

It is usually reported that, on average, 10 percent of people with anorexia nervosa are males, although this may be underestimated. Indeed, boys and men are less likely to be aware of having an eating disorder and are often more reluctant to seek help. Indeed, even if they are aware that they need help, males are less likely to seek treatment for their eating disorders, likely due to gender stereotypes and the idea that eating disorders are something that only affects women. When males finally go to the doctor about their eating disorder, they have often been ill for a long time, making it more difficult for them to recover.

Moreover, the questionnaires and interviews used to assess for eating disorders have been specifically designed for women. We may not be asking the right questions for detecting eating disorders in boys and men. For example, a question like "I frequently check my muscles" is not usually asked during an eating-disorder exam, while others like "I think my thighs are too large" are.

Despite the above problems, a high rate of eating disorders in males has been reported by a recent Australian study that found a 12.8-point prevalence of any eating disorders among adolescent boys. The most common disorders were other specified feeding and eating disorders (8.5 percent), night eating syndrome (4.9 percent), bulimia nervosa (1.8 percent), unspecified feeding and eating disorder (UFED; 1.3 percent), and atypical anorexia nervosa (1.2 percent). However, no case of anorexia nervosa was detected. In light of these data, it is no longer tenable to state that eating disorders are rare among males.

There is also evidence of an increased rate of eating disorders in sexual minority men and boys.

Eating Disorders' Features in Males

The main differences between males and females with eating disorders and disordered eating are body image concerns and associated behaviors.

A recent US survey showed that about 30 percent of adolescent boys report attempting to gain weight or increase their muscle mass. Interestingly, among these boys, 39.6 percent were normal weight, 12.8 percent were overweight, and 10.6 percent were obese. On the contrary, the rate of girls who reported attempts to gain weight was only 6.5 percent. In addition, disordered eating behaviors seem more common in young men who are overweight than in those who are normal weight.

While the primary concern of women and girls with an eating disorder is being too fat, males tend to be concerned about not having enough muscle mass. This is probably why males with eating disorders are more likely to exercise excessively than purge for weight control, even after binges. In addition, while females with eating disorders often avoid high-calorie food items, males tend to tailor their diet to muscle-building, increasing their intake of proteins and creatine supplements, perhaps even resorting to misuse of steroids, growth hormones, and other substances. These are sweeping generalizations, but it appears that what is recognized as the “relentless pursuit of thinness” in females manifests in males as the “relentless pursuit of muscularity.”

However, I must say that in my clinical practice, I have seen some males, especially those suffering from anorexia nervosa, reporting a morbid fear of weight gain, a marked desire for thinness, and similar eating disorder features to females.

Although there are little data available, a history of obesity (about 50 percent), depression, substance misuse (drug and alcohol abuse), and/or suicidality is more common in males with anorexia nervosa than in the general male population.

Medical Complications

Males with eating disorders suffer from many medical complications. These are the consequences of undereating and underweight, excessive exercising, and purging behavior.

Undereating and being underweight cause the male hormone testosterone to drop. Consequently, they have a reduced sex drive and low sperm count and viability. Furthermore, drugs taken to enhance musculature or reduce weight can play havoc with hormones and, consequently, sexual function and development.

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While in the general population osteoporosis is much more frequently seen in females, males with anorexia nervosa also may have severe osteoporosis. Malnourishment in teenagers, before the bones are fully developed, can also cause growth to slow down or stop entirely.

Undereating and low weight produce muscle loss, and weakness may result. When the person is severely underweight, there is a dramatic drop in fitness. This leads to their having difficulties walking up the stairs, squatting, or standing up from sitting.

Extreme dieting and low weight can also profoundly impact the heart and blood vessels. Heart muscle is lost and becomes weaker with malnutrition and excessive weight loss. Blood pressure becomes low, as does the heart rate. Persistent low body weight also increases the risk of a dangerous alteration in heartbeats, especially if there is a significant electrolyte imbalance (e.g., low potassium level) due to self-induced vomiting and/or misuse of laxatives and diuretics.

Other features include a high level of cholesterol, low white cells (neutropenia) and red cells (anemia), slow gastric emptying with digestive symptoms, and alteration of liver enzymes.

Treatment

Few data are available on the treatment outcome of males with eating disorders. Indeed, in current female-dominated treatment studies, males are often excluded as they are considered “atypical.” Moreover, residential and partial hospital programs still have limited capacity to treat men with eating disorders.

A recent study has reported the clinical outcomes among 119 males with eating disorders (60 with anorexia nervosa and 49 with bulimia nervosa). The study found that remission rates were similar among males and females with anorexia nervosa at the end of treatment (40 percent remission), but males reported more disordered eating at follow-up. On the contrary, the remission rate was lower in males than in females at the end of the treatment (44 percent vs 50 percent). A worrying fact is that males with anorexia nervosa seem to have a higher standardized mortality than females with anorexia nervosa.

The treatment of males with eating disorders is similar to that of females. The same evidence-based psychological treatments are recommended. However, the treatment should be tailored to the specific needs of males, addressing some specific features of eating disorders, such as the overvaluation of the muscle shape and its expressions (e.g., dietary rules aimed at muscle growth, excessive exercise, shape muscle checking and avoidance) and exploring the gender socialization and beliefs about masculinity in the maintenance of their eating disorders.