In honor of Father's Day coming up, I thought it was fitting to talk about men, specifically male eating disorders. I realize the stereotype of eating disorders is a thin, white young woman, but we must acknowledge the prevalence and impact on men.
I love my facts and figures, so let's hit on those for a second.
In addition to the stereotype of the thin, white young woman, there is also the stereotype that if an eating disorder affects a man, it is a gay or bisexual man. And eating disorders indeed affect a more significant proportion of gay and bisexual males. Still, when you apply the percentages to population figures, more heterosexual men are diagnosed with an eating disorder.
When you look at subclinical eating disorders (i.e., clinical presentations that meet some but not all the diagnostic criteria for a diagnosis), the rates are nearly the same for men and women.
Although it is an older study, Hudson and others (2007) found that men represent 25 percent of anorexia and bulimia nervosa cases and 36 percent of binge eating cases.
This may be a refresher for some, but I want to discuss how people express their gender. We typically think of feminine and masculine as the only two options, but gender expression is on a continuum and a separate continuum from gender. For example, a cis man can lean more toward the masculine or lean more toward the feminine. Similarly, a cis woman could express their gender more masculinely or lean into their feminity. Same with all genders.
Okay, so why the gender studies diatribe? Because so much of the male eating disorder is tied to societal and self-imposed stereotypes of masculinity. It would be difficult to discuss how men with eating disorders differ from females with eating disorders without exploring this point.
Western culture depicts masculinity as the strong, protector type. Masculine individuals show less emotionality because they attribute the expression of emotion to being weaker. In some extreme representations of masculinity, it is depicted as aggressive and disregarding others.
The masculine male is the Alpha (even in movies like Up, where the lead dog is named Alpha), and all other males are Betas (leaving no room for variation). So the Alpha is John Wayne, the Marlboro Man, and James Bond all rolled into one. He doesn't have to be a womanizer because women flock to him (i.e., sending the message that any men not attracted to women are, by default, Betas).
Hopefully, you are getting the picture that the masculine/feminine dichotomy does not represent many men. So to understand how eating disorders present in men, we have to re-educate ourselves and the people we work with.
To truly support male clients seeking eating disorder treatment, we need an approach tailored to their needs, and that is affirming their identities as men. That starts with a thorough assessment. It should go in-depth with questions about identity. Questions like, "Point to where on this continuum you identify when expressing your gender" or "How do you express your gender?" should be asked. Tailor intake questionnaires and clinical interview guides to ensure that gender-specific questions are excluded. For example, I would imagine a cis male client (who is already telling themselves that they shouldn't be seeking treatment for a "women's disorder") might hesitate to return to therapy if asked questions about menses.
I firmly believe that too many clinicians shy away from education in therapy, and it is so essential. We should not assume that every client entering treatment understands how long sessions will last, what their disorder looks like, or what is okay or not okay to discuss. The same goes with educating about topics that influence their treatment, such as gender expression. So the second way we can tailor eating disorder treatment for men is to provide education on gender, gender expression, their disorder, and the treatment they will receive.
For men that identify with a more masculine gender expression, we should consider the differences. Treatment approaches that rely heavily on identifying, sitting with, and expressing emotions may not be the best interventions for masculine-identifying people. Instead, utilizing strength-based interventions may have a more significant effect on outcomes. For example, when working with a heady individual who intellectualizes everything, a bit of movement (instead of emotional work) may land better. Tell them to get up from their seat for a second and stretch. Ask them to sit back down and then move on to the next topic. You have the same effect of getting them out of their head.
Just with any client, it is crucial not to make assumptions. Ask them what their ideal body is. Most men are not striving for a thin frame. Do this work early in the course of treatment (and ongoing). It will aid in tailoring interventions. For example, instead of focusing on a weekly recall of restricting behaviors, I may focus on exercise behaviors.
Just because they may not need to express their emotions as openly as others does not mean that they do not need validation, men are human, and validation is an innate need we all have within us. So be sure to listen and validate. Like above, do not assume but ask and then validate.
Lastly, we need to listen to meet their needs (as well as validate). Maybe they need a male therapist. Perhaps they need a different approach.
Just as there are many different people, personalities, and identities, each person may need a slightly different approach. Therefore, the points above are considerations but are not an end-all-be-all to treating male eating disorders. If you are a therapist who needs consultation on a case or a man seeking treatment for an eating disorder, I invite you to reach out to me.
Hudson, J., Hiripi, E., Pope, H., & Kessler, R. (2007) "The prevalence and correlates of eating disorders in the national comorbidity survey replication." Biological Psychiatry, 61, 348–358.
Mitchison, D., Hay, P., Slewa-Younan, S., & Mond, J. (2014). The changing demographic profile of eating disorder behaviors in the community. BMC Public Health, 14(1). doi:10.1186/1471-2458-14-943
Zhao, Y., Encinosa, W. Update on Hospitalizations for Eating Disorders, 1999 to 2009. HCUP Statistical Brief #120. September, 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb120.pdf