There’s a question that has swirled around the eating disorder field for decades: Where are all the males?
Our understanding of eating disorders in males is limited because the field has historically focused on females. Research has centered on females, diagnoses were organized around them, and screening tools and assessments have been normed to them.
We don’t have research that establishes what it means to have an eating disorder if you are male. We can approximate the population of males with eating disorders as 1/3 of the total number of people with eating disorders—but then the question arises: Why? Why would so many fewer males than females be affected?
It is unlikely that having two XX chromosomes instead of one X and one Y is the reason. Therefore, we must search for other factors to help us understand and explain the significantly lower rate in males. Are we missing the males with eating disorders?
Looking at disordered eating behaviors in areas other than eating disorders is one place the search takes place. When we examine areas where disordered eating may be present in males, we can ask whether these males may be struggling with food and body in a way that has gone unnoticed and untreated.
Two areas of interest are muscle dysmorphia and sports.
Muscle dysmorphia is a condition that involves a preoccupation with muscularity. Like body dysmorphia more generally, it brings anxiety and distress about perceived flaws in one’s appearance. Males affected by muscle dysmorphia perceive their bodies to be lacking in muscle.
These males will likely not talk about a desire to be thin. More likely, they will talk about a desire to build muscle and lower body fat. They might talk about their workout habits, bodybuilding regimens, or supplement use meant to “bulk” up or “sculpt” their bodies. Unlike body image concerns underlying a desire to be thinner, muscle dysmorphia involves a desire to become bigger and leaner.
But if we ask further, we may find that these males are actually obsessed with food and body. It is not uncommon for males experiencing muscle dysmorphia to exercise excessively, adhere to strict diets, and engage in other disordered behaviors. We often find that their preoccupation and impairment are not unlike those suffering from more traditional eating disorders—and that their eating disorders have long gone unnoticed.
Another area where we may find males suffering from unrecognized eating disorders is sports. We believe that roughly 60% of males with eating disorders are involved with sports, but their symptoms may be masked as “normal” behavior for their sport.
Disordered eating does not always constitute an eating disorder, but it is a sign that we should ask more. When we ask male athletes about their relationship with food and body, we may find that they are experiencing many of the traditional physical, emotional and behavioral signs of an eating disorder.
When it comes to males and eating disorders, we want to open a wide lens. We want to explore the ways social factors can contribute to the development or maintenance of eating disorders. We want to be aware of how we may approach a male with an eating disorder differently than a female with one, and how we can challenge the stereotype of eating disorders as a “women’s disease.” This stereotype and the stigma associated with it keeps males from seeking help.
We will continue to see people whose symptoms do not fit neatly within the DSM categories but whose underlying concerns about weight and body are identical to those who do fit the traditional categories. It is extremely important that we continue to look at these groups and care for the suffering of anyone struggling in their relationship with food and body.
Dr. Mark Warren is the Chief Medical Officer for The Emily Program and Veritas Collaborative. He is also one of the original founders of the Cleveland Center for Eating Disorders, which became The Emily Program – Cleveland in 2014. A Cleveland native, he is a graduate of the Johns Hopkins University Medical School and completed his residency at Harvard Medical School. He served as Chairman of the Department of Psychiatry at Mt. Sinai Hospital and Medical Director of University Hospital Health System’s Laurelwood Hospital. A past vice-chair for clinical affairs at the Case School of Medicine Department of Psychiatry, he continues on the Clinical Faculty of the Medical School, teaching in both the Departments of Psychiatry and Pediatrics. He is currently a faculty member and former chair of the Board of Governors at the Gestalt Institute of Cleveland. Dr. Warren is a Distinguished Fellow of the American Psychiatric Association, a two-time recipient of the Exemplary Psychiatrist Award of the National Alliance for the Mentally Ill, and a winner of the Woodruff Award. He leads the Males and Eating Disorders special interest group for the Academy of Eating Disorders.
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