When I meet new people and tell them that I am a clinical psychologist, I usually hear one of two questions. Question one – “Are you analyzing me?” – can be answered rather succinctly (“I wasn’t, until you just said that.”).
Question two – “Do you have a specialty?” – is a trickier ask to answer. I might respond that I specialize in the practice of psychotherapies like cognitive behavioral therapy and interpersonal therapy, and the development and testing of novel psychotherapies. But then I must explain what that means. In an effort to keep it brief and move the conversation along, I might say simply, “Eating disorders.” I do, after all, spend part of my time at the New York State Psychiatric Institute/Columbia Center for Eating Disorders. If this is my response, then I am likely to hear Question 3: “So you only treat women?”
No. In my years of working with individuals with eating problems, I have certainly treated male patients. Men with anorexia nervosa. Men with bulimia nervosa. Men with binge eating disorder.
In a country and culture that has historically defined eating disorders and preoccupation with appearance as a “women’s issue,” men suffering from body image and eating problems have a stigma to overcome. It is true that more women are affected by eating disorders than men, as is also the case for many anxiety and mood disorders. However, recent U.S. survey data of lifetime eating disorder prevalence suggest that binge eating disorder is about as common in men as women, and that for both bulimia and anorexia nervosa, men represent approximately one-fourth of the cases. Prior studies put forth a more modest, albeit still quite concerning, estimate with roughly one-tenth of cases of bulimia and anorexia nervosa being male.
Men may be more likely to be misdiagnosed and less likely to receive specialized treatment, but they certainly can still suffer from these conditions. Perhaps acknowledging the issue of potential misdiagnosis of anorexia nervosa, the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (a diagnostic dictionary for mental health providers) made an important change to the diagnostic criteria for the condition. The amenorrhea criterion, which stipulated the absence of a menstrual period for 3 months to receive a diagnosis, was removed. This feature, frequently but not always present in women, might have primed clinicians not to consider boys and men for the diagnosis; its removal may help more males with anorexia nervosa to be properly identified.
But to me, the most important thing to understand about eating disorders in men is that the presentation can be nearly identical to that of women. Males with anorexia nervosa, for example, are underweight for their height (or, in the case of still-growing boys, for their age and expected growth curve) and afraid – of eating fat, of gaining weight, of becoming fat. Males with bulimia nervosa are stuck in a complex web of extreme food restriction rules which, when inevitably broken, lead to feelings of guilt and shame, binge eating episodes and then purging (by means including self-induced vomiting and laxative misuse). Men with binge eating disorder feel as out-of-control when they binge eat as do women with the same condition, and they just as distressed by the binge episodes they regularly experience. For many men with eating disorders, their appearance is an essential, primary way in which they evaluate themselves, yet they do not seem to measure up at any size.
Are there differences between men and women with eating disorders? Sure, research in this area does suggest a few. The motivation for men and boys to control or influence appearance may, in some cases, be different. For instance, whereas our culture seems to emphasis form over function for women’s body, function – speed, strength, ability to fight – remains awfully important for men. Male body dissatisfaction may be rooted in actual or perceived difficulty with physical performance rather than appearance. (Though, the same may be said of female athletes.) Women and men with eating disorders who abuse substances like laxatives, diuretics, or diet pills in a misguided effort to lose or control weight (these substances mostly dehydrate the body or slow motility while building tolerance over time), but men are more likely to have tried a class of illegal substances called APEDs, appearance and performance enhancing drugs. APED use is associated with increased risk for eating disorders and body image problems. The common thread here is the persistent use of harmful substances, hazardous in type, quantity or both, in the name of “health.”
If we can accept that (1) men can have eating disorders and (2) there is more similarity across the sexes than difference (acknowledging, of course, enough heterogeneity for each individual to have his or her own narrative of the illness and experience in recovery), then identification and treatment of men can improve.
Men with anorexia nervosa, suffer from the same physiological effects of malnutrition as women (in fact, the seminal study about these effects were done in men) and must, first and foremost, normalize their weight and physical health to have a chance at truly restoring psychological health. Men with bulimia nervosa and binge eating disorder must break their food rules and normalize their eating – what, when and how they eat – to put a stop to binge eating. Those with bulimia nervosa must additionally learn that purging is not an effective way to control weight, and they must develop other strategies to cope with difficult emotions, discomfort after eating, and other circumstances that trigger the behavior. No matter the diagnosis, improvements in body image and body satisfaction are likely to lag behind the rest for men, as is the case for many women.
For those with acute, severe disturbances in eating and weight, behavioral treatments, sometimes within the structure of programs that provide supervision during and after meals, may be required. A multi-disciplinary treatment team, including a dietician, psychotherapist, and medical doctor such as a psychiatrist or primary care physician, may be beneficial for outpatient care. The same medications sometimes used to treat women with bulimia nervosa and binge eating disorder can be used to treat men. Involvement of loved ones – a family of origin or of the patient’s choosing – is likely to help men get and stay well, just as it does for their female counterparts. And of course, early identification of these illnesses – like many others – may confer the best chance of quick, sustained recovery.
An earlier version of this post appeared in the The Huffington Post on October 2, 2015.