Eating disorders (EDs) are multifactorial conditions characterized by disordered eating behaviors with various root psychological causes. While societal perceptions of EDs are commonly associated with females, these behaviors are not gender-specific.

Contemporary estimates suggest that approximately one in four people with an ED is male.

Sangha S, Oliffe JL, Kelly MT, et al. Eating disorders in males: how primary care providers can improve recognition, diagnosis, and treatment. Am J Mens Health. 2019;13(3):1557988319857424.

Given the erroneous perception that EDs only affect females, males with the disorder typically present at later stages of the disease, are misdiagnosed, and have delayed treatment.

 

But there are strategies to help prevent this from happening.

 

Prevalence of delayed presentation, diagnosis

In interviews with MDLinx, prominent researchers and clinicians involved in the treatment of EDs discussed the current pitfalls in ED recognition and diagnosis in males, as well as potential opportunities to overcome these challenges.

Stuart B. Murray, DClinPsych, PhD, Della Martin Associate Professor of Psychiatry at the University of Southern California Keck School of Medicine, told MDLinx that much of the research on EDs has focused primarily on females and excluded males. This has likely perpetuated the stereotypes that EDs don’t affect males and contributed to the lack of male-centered knowledge relating to ED care.

“As a result, we have things like amenorrhea as a diagnostic criteria for eating disorders,” Dr. Murray said, suggesting that the current level of research and consequential diagnostic recommendations aren’t fully inclusive of all sexes.

I think we've just become that generation of physicians that's accustomed to thinking that these things don't affect boys and men, so we're not asking the right questions.

Dr. Murray, who serves as the Director of the Eating Disorders Program and Translational Research in Eating Disorders Laboratory at USC, added that when it comes to EDs, people often think about the classic symptoms of anorexia nervosa. “But probably the most common eating disorder in men is muscularity-oriented, because that's most aligned with the Western portrayal of the male body ideal,” he stated.

Anorexia nervosa, for instance, is not as frequently observed in males, but the drive toward leanness could facilitate symptomology of the condition, including rapid weight loss and emaciated appearance.

Murray SB, Rieger E, Hildebrandt T, et al. A comparison of eating, exercise, shape, and weight related symptomatology in males with muscle dysmorphia and anorexia nervosa. Body Image. 2012;9(2):193–200.

 

 

The ongoing myth

Caryn Honig, EdD, MEd, RD, LD, founder of Dr. Caryn Honig Nutrition and adjunct professor at the University of Houston, explained to MDLinx that there is a continual myth among the public and even among clinicians that EDs predominantly affect only White, middle-to-upper class girls and women. 

EDs do not discriminate.

According to Dr. Murray, many male patients with EDs are often misdiagnosed and/or experience considerable delays in diagnosis. He also noted there’s a persisting stigma in the public and medical community regarding male EDs.

We misdiagnose them and we shame them, and it makes it much, much harder for guys to come forward.

“And I think even when they do come [forward] and speak with a professional, they often get asked questions that aren't really related to their concerns," he added.

“There is still so much societal and cultural shame, stigma, and judgment surrounding males and EDs,” Dr. Honig added. “Also, there is the issue of toxic masculinity and the belief that men must always keep ‘stiff upper lips.’”

Dr. Honig noted that the initial physical, mental, or emotional signs and symptoms of EDs in males are often attributed to other illnesses due to gender bias. “Clinicians often use language geared towards women and girls, and the assessments and screening contain language that is geared to females,” she explained.

 

Impact of delayed detection

Unfortunately, delayed ED diagnoses can have significant clinical ramifications. “We know that as long as someone has an ED, the more likely they are to have medical complexity, and that’s what we want to try and avoid,” Dr. Murray said.

Dr. Honig stated that several physical complications can result from EDs, including bone loss, cardiovascular complications, dehydration, gastrointestinal distress, malnutrition, altered mental state and cognition, and weakness, among others. “If unidentified and left untreated,” she said, “many of these health consequences can potentially lead to multiple system failure in the body, and can potentially be fatal.”

Dr. Honig noted that while most of these complications can be reversed with nutritional therapy, osteoporosis and cerebral atrophy can be permanent if the ED remains untreated or undertreated.

Dr. Murray added that given the high medical risk associated with EDs—particularly in patients who have delayed recognition—early intervention is key. “Generally, EDs respond well to treatment if you can treat them within about a year of onset,” he explained. “If you don't get them within that window, they can [become] quite chronic quite quickly.”

“Furthermore, studies indicate that the risk of mortality for males with EDs is higher than it is for females; therefore, early intervention is critical,” Dr. Honig commented.

 

Improved awareness is critical

In addition to lack of awareness of EDs in males among many clinicians, many males fail to recognize eating disordered behaviors in themselves, further delaying presentation.

Räisänen U, Hunt K. The role of gendered constructions of eating disorders in delayed help-seeking in men: a qualitative interview study. BMJ Open. 2014;4(4):e004342.

 

However, greater knowledge among these clinicians is necessary to improve early diagnosis and treatment uptake in males.

In a 2019 paper published in the American Journal of Men's Health, Sangha and colleagues suggest that in addition to looking for extreme thinness, PCPs and other clinicians should be aware of males’ reported desire to achieve extreme muscular bodies with low body fat. Additionally, given that some ED symptoms may not be observable in males in the clinical setting, the researchers noted that clinicians need to remain cognizant of the subtle risk factors for EDs.

Dr. Murray added that greater dissemination of information regarding EDs in males is needed to achieve better outcomes in this population. Despite the importance of communicating male EDs in medical publications, Dr. Murray commented that many editors of broad-focus medical journals will likely refer these types of articles to specialty journals. So the information may reach a much smaller audience who already understands the data, resulting in further awareness gaps in the larger medical community.

“It would also be helpful if clinicians, teachers, coaches, and parents are made aware of the common comorbid conditions of men who are struggling with EDs,” Dr. Honig said. “These conditions include anxiety, depression, over-exercise, and substance abuse.”

In addition, Dr. Honig stated that treatment of EDs is not a one-size-fits-all approach, suggesting that clinicians should understand the complexity involved in managing the disorder, regardless of the patient’s sex.

“Nutrition, food, and weight are all so individual and complicated,” she said. “Treatment needs to be individualized."

Biological, cultural, familial, and societal factors all need to be taken into consideration for appropriate treatment to occur.

Patients should also understand that they are not alone and that help is out there. The National Eating Disorders Association (NEDA) is a resource they can be referred to for more education and information. NEDA can be contacted at 1-800-931-2237 or by texting NEDA to 741741 for immediate assistance. The National Association of Anorexia Nervosa and Associated Disorders also provides free peer support services at 1-888-375-7767.