Eating Disorders in Underrepresented Male Populations
Negligence in treating men who display eating disorder (ED) symptomology begins with the history of the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). For example, in the DSM-IV-TR, to satisfy a diagnosis of Anorexia Nervosa (AN), it states that an assigned woman at birth (AWAB) must, “have an absence of three consecutive menstrual cycles for a diagnosis” (p. 589). Gender-focused criteria could contribute to the hesitation a clinician encounters when diagnosing an assigned male at birth (AMAB) with AN. Across ED criteria and research, the language does not include males as frequently (Jackson, 2008). The fifth edition of the DSM has since evolved and eliminated much of its gender-focused criteria but eating disorders in men are still so woefully underrepresented and under-researched.
Although the DSM-5 describes seven feeding disorders, we are limiting the scope of this review to the most frequently reported disorders, AN, bulimia nervosa (BN), and binge eating disorder (BED). According to the DSM-5 when looking at population norms, the female-to-male ratio of experiencing AN is 10 to one. The 10 to one female to male ratio is also occurring in BN. In the US population, BED occurs in females and males 1.6% and .8% respectively. A consistent statement written under nearly every feeding disorder in the DSM-5 is, “less is known about the prevalence in males” (American Psychiatric Association, 2013). The experience of male and female EDs are generally studied similarly and conclusions to female studies are erroneously applied to different masculine gender identities (William & Morgan, 2010).
Biological gender differences with weight and body image is influenced by body mass index (BMI), a critical diagnostic criterion within EDs. The average BMI for men falls under the “obesity” category. Whereas for women, the average BMI falls within a “normal” range. Therefore, men report being underweight or average weight more often from this skewed scale. Due to the stigma that EDs only affect women, fewer men are willing to openly discuss their disordered eating or body image issues (William & Morgan, 2010).
The pathology of eating disorders in men is misunderstood. According to Rebecca M. Shingleton and colleagues (2015), about 70% of men do not report concerns regarding their shape or weight in clinical trials. This leaves the 30% of men who endorse significant concerns, with little research performed on this population. The purpose of this review is to explore the clinical presentation of EDs in underrepresented men through identities such as age, sexual and affectional identity, gender identity, and racial and ethnic minorities.
A commonly accepted stereotype of EDs is that it only affects young White women, there is a lack of understanding on men and how men with disordered eating differ from men without disordered eating (Tylka & Subich, 2002). Among men, four factors may contribute towards EDs: gender role conflict, attitudes towards help seeking, symptom recognition, and media influence. It is believed that the stigma in help-seeking and ability to recognize symptoms prevent men from receiving treatment (Jackson, 2008). This could potentially be attributed to the overall lack of education surrounding the ways in which EDs manifest in masculine-identified individuals.
There are distinct differences in the expectations of which masculinity, femininity, and androgyny are expressed and, thus, lead to differences the way that masculine-identified, feminine-identified, and nonbinary individuals view and critique their bodies. Given the varying beauty ideals across genders, the desired physical appearance may differ, ultimately affecting pathology. Typically, within women, thinness is the desired characteristic; in men, it is muscularity. The ideal body for women is to be tall and slender. Consequently, many women feel overweight. As the ideal body for men is lean and muscular, many men feel weak and small (Morgan & Arcelus, 2009, p. 436).
Further, for gender diverse (GD) individuals, differing idealized body types often combine with body-focused gender dysphoria to manifest in distinct beliefs about one’s gender expression and body. For GD individuals seeking an androgynous gender expression, taller and thinner bodies are often idealized through media representations (i.e., Tilda Swinton). This idealization may lead short GD individuals or those in larger bodies to feel small and/or overweight, in addition to feeling as if their bodies are not aligned with their gender identity or desired gender expression.
Men report more dissatisfaction with the muscle size and shape of their bodies (Jackson, 2008). Men may also have low insight and awareness of the possible dangers of unhealthy weight control techniques. Additionally, men report different reasons for weight control: they are typically more dissatisfied with their bodies in the sense they want to be more muscular, instead of the thinness preoccupation seen in females. They may see dieting as a way to get to a specific goal, rather than an ongoing lifestyle (Tylka & Subich, 2002). The specific area men may be particularly attuned to is their upper torso, as they aspire for it to be as muscular as possible. Men typically control their weight to prevent obesity, improve sports performance, and to avoid weight-related medical complications. Men also use bingeing and over-exercising as a purging mechanism because it is more socially acceptable as a means of weight control (William & Morgan, 2010).
Men still experience body objectification, dissatisfaction, and exposure to unobtainable body image ideals just like women. Since men desire to have a lean and muscular body, this can lead to under-diagnosing EDs in the male population because the more reflective pathology differs from the DSM-5. For men, body disapproval can stem from a drive for muscularity, variability between real and ideal body size and shape, and unhappiness with general body proportion or specific parts (Picot, 2006). The classification of EDs is skewed against men, as the criteria for diagnosis may not include their pathology (William & Morgan, 2010). It is believed that eating disorders in males are probably under-reported as a result of the stigma affiliated with female qualities, such as the desire for thinness. Many males do not meet criteria for AN or BN, but they are more likely to be classified as other specified feeding or eating disorder (OSFED) or BED (Picot, 2006).
Studies on men and vulnerability in developing eating disorders are completed considerably less often than those for women. This could be due to EDs frequency among gender identities. Heterosexual males had the lowest level of disorder eating symptoms and body image, size, or shape concerns compared with gay men and lesbian and heterosexual women (Strong, Williamson, Netemyer, & Geer, 2000). One study used the Body Shape Questionnaire (BSQ) to assess gender and sexual orientation differences within eating disorders. The BSQ is available in female and male versions, using she/her/hers and he/him/his pronouns. The BSQ is positively associated with body size, shape disapproval, and dietary restraint. The researchers found that there was no significant correlation with body image dissatisfaction and heterosexual males, which varied from the three other groups: gay men, lesbian women, and heterosexual women. Additionally, heterosexual men also had low rates of supporting eating disorder symptoms, there was very little variability within their group as well. There was, however, some evidence of cognitive influence. “For heterosexual males, sociocultural influences from media which promoted thinness entered as the strongest correlate of eating disorder symptoms” (Strong et al., 2000, p. 11). This suggests that media plays an important role in developing the ideal male body type. Despite this, there was very little internalization of the influences. Therefore, social environments that endorse body ideals, such as certain shape or size and desire thinness, are more likely to be associated with higher rates of an ED (Strong et al., 2000).
There is a social trend occurring in men that encourages muscularity (Picot, 2006). Men were interviewed at fitness clubs were observed to have abnormally rigid mentalities towards their bodies, diet, weight-lifting, and anabolic steroid use (Picot, 2006). The term “muscle dysmorphia” was developed as a way to describe individuals who have a severely distorted body image that impairs their social and occupation functioning. Muscle dysmorphia is now a specifier for body dysmorphic disorder (American Psychiatric Association, 2013) and is a step towards understanding disordered eating and body image issues in men.
Sexual and Affectional Orientation
Previous research has claimed that affectional (romantic) and sexual orientation is a critical aspect in understanding vulnerability to developing an ED, specifically among gay men (Picot, 2006). The ideal gay male body is thin and muscular, which makes them more vulnerable to disordered eating (Boisvert & Harrel, 2009). The gay male community’s definition of attractiveness is heavily based on having a lower body weight and muscular leanness (Boisvert & Harrel, 2009). It has been studied that there is an association with gay men and BN, where in AN, it is more prominent in men who identify as asexual (William & Morgan, 2010).
Research posits that about 20-33% of males with eating disorders identify as gay (Picot, 2006). Studies examining eating behaviors in men have shown that gay men are at a higher risk for developing detrimental attitudes and disordered thinking around eating. Although the rate within the clinical environment of gay men is high, researchers do not know if in community settings it is equally as prominent. Due to community stressors and norms, gay men may experience more pressure to conform and modify their bodies to be thin. If an individual does not like their body, they are more likely to diet (William & Morgan, 2010). Gay male body disapproval is thought to be a result of a discrepancy between ideal body types and the way they see their current bodies; which varies from heterosexual men. Additionally, gay men are more likely to associate physical characteristics with their self-identity, such as their physical appearance and desirability. This leads to a greater drive for muscularity and heightened physical attractiveness, which is the antithesis of their heterosexual counterpart, who tend to desire just general health and wellbeing. Overall, gay men place a higher emphasis on appearance and desire a thinner body structure (Picot, 2006).
Media and peer influence appeared to be relevant among gay men as well (William & Morgan, 2010). Increased media internalization is correlated with higher eating disorder symptomology among gay men. “Results indicate that gay men have greater media internalization associated with higher levels of eating disorder symptomology” (Picot, 2006). Increased levels of femininity were correlated with body dissatisfaction among gay men. Additionally, a diligent concern with their appearance may stem from the desire receive acceptance or to attract a potential partner (William & Morgan, 2010). Gender identification, specifically for gay men, can also lead to higher vulnerability to develop an eating disorder (Picot, 2006).
Low self-esteem may be a consequence of this cognitive processes. It is possible that due discrimination of an individual’s sexual and affectional orientation, one may be at a greater potential risk to an ED from accompanying psychological stress (Picot, 2006). This desire to fit in and adjust one’s body to societal pressures may stem from the norms and values of the gay community, an already marginalized population. The need to conform creates low self-esteem and low body image satisfaction (William & Morgan, 2010). Adding a mental health illness can create even more isolation and deter help-seeking behaviors. Discrimination of one’s sexual and affectional orientation has been seen to exacerbate the course of an ED. It has also made gay men more predisposed to other mental health disorders such as higher levels of depression, and low self-esteem. Gay men reported a significantly lower BMI than their heterosexual counterparts and had greater weight discrepancy (Boisvert & Harrel, 2009). Alternatively, sexual orientation can provide protective factors. Gay men are more likely to be exposed to mental health services due to their heightened vulnerability to mental health illnesses and trauma. Moreover, studies have shown that gay men are more likely and open to talking about the experience of their eating concerns compared to their heterosexual counterparts (William & Morgan, 2010).
“Homonegativity” occurs from the internalization of pejorative stereotypes associated with being gay (Picot, 2006). It can cause self-loathing, which later can manifest as an eating disorder. Stereotypes continue affecting the psyche of gay men: after the AIDS epidemic struck the gay male community, the community was viewed as ill or weak. As compensation, community individuals began to focus on a healthy and fit appearance. On another cultural level, some gay men might desire to be fit as a way to compensate for a lack of traditional maleness that is often perceived with being gay (Picot, 2006). Overall, the adversity associated with identifying as a gay man is correlated with higher risk of ED symptoms.
Gender Diverse Identities
Exploring the impact and prevalence of EDs in gender diverse populations can prove to be difficult due to the complicated nature of working within a binary gender system that does not account for gender diversity. When considering the impact of gender on EDs within individuals AMAB, we must consider that while not all of those individuals will identify as male, many will be viewed in society as masculine and have masculine gender norms forced on to them. Conversely, individuals AFAB will have feminine gender norms forced on to them even if they do not identify as feminine. As stated above, gender norms impact body image which, in turn, impacts the development of EDs.
Research on disordered eating in gender diverse identities is limited, often with studies that lump all gender identities into one category or overlook nonbinary identities entirely. However, growing research is indicating that GD individuals’ experience of body dissatisfaction and disorder eating behaviors may be different than that of their cisgender peers (Nagata, Ganson, & Austin, 2019). Body image in GD individuals is influenced by a combination of gender-focused body dysphoria, societal expectations, and negative body image (Testa, Rider, Haug, & Balsam, 2017).
Within the GD population, both gender identity and sex assigned at birth play unique roles in prevalence of EDs, with higher prevalence of ED in transmasculine individuals (Witcomb et al., 2015). Witcomb and colleagues (2015) theorize that this increased prevalence may be related to a transmasculine person who is AFAB being regularly exposed to messages regarding an idealized body size or type. Further, body dissatisfaction is a common component of both EDs and gender dysphoria, increasing comorbidity between EDs and experiences of gender dysphoria (Testa et al., 2017). One study found that transmasculine individuals tended to endorse overall body dissatisfaction rather than a dissatisfaction with gender-specific body characteristics (Becker et al., 2016). The important distinction to be made is that transmasculine individuals are masculine and treatment for their EDs should align with their gender identity, rather than the sex they were assigned at birth. The role of gender affirming medical care in treatment must also be considered; transmasculine individuals with EDs may benefit from access to gender affirming medical care as it may increase affirmation of identity and increase body satisfaction (Testa et al., 2017).
Nonbinary and gender expansive identities must also be considered in terms of EDs. Namely, the prevalence of both disordered eating and EDs, the ways in which symptoms may manifest, and the treatments that may be most effective should be further investigated.
Delayed onset of an ED in older adult men is still not fully understood in the psychology community. Research on older adult males with eating disorders is even more poorly established than males with eating disorders in general (Diaz, 2012). What has been established, however, is that eating disorders appear to have a later onset in men than in women as a product of life transitions, loss of physical fitness, decline in control over bodily functions, and lowered self-esteem (Diaz, 2012). Body image changes throughout a male’s lifetime, dissatisfaction may increase with age. Age and body dissatisfaction did not have a significant correlation, there are other variables contributing to men developing eating disorders later on in life. Using the Draw a Person (DAP) exercise, older men were asked to draw what they thought their body looked like to better understand their insecurities. Used in conjunction with the Body Cathexis –Self-Cathexis Scale (BC-SC), a self-report questionnaire that investigates approval over body parts and life goals, it was noticed that older men have shown they are more upset with a decline in physical fitness rather than their body image. This is interpreted by high DAP score but low BC-SC score, believing that a male’s self-esteem is more involved with autonomy instead of body approval. Their lack of muscularity did not bother the individuals so much as their lack of physical fitness, body functioning and life goals. This is congruent with a man’s self-esteem beginning to rise after 18 then decrease in middle adulthood to 60-years-old, finally to drastically decrease around 70-years-old. This change can be attributed to loss of a spouse, retirement or other life transitions (Diaz, 2012).
Research has shown three themes within older adult males and EDs: loss and unworthiness, fear of becoming bigger, and wanting change (McCormack, Lewis & Wells, 2014). The catalyst identified has been an emotional tipping point. Loss and unworthiness are operationally defined by the feeling of numbness, mental blocks, struggling sense of self, and poor relationship problems (McCormack et al., 2014). This can derive from family history, feelings towards parental treatment, or possible trauma and abuse causing the individual to try to change his or her food patterns (Picot, 2006). It was hypothesized that older gay men may be even more at risk in developing eating disorder symptoms, as gay culture emphasizes a “trim and fit body type” (Boisvert & Harrel, 2009). As one ages, it is more difficult to maintain physical fitness and the ideal body type. This difficulty may cause shame, which makes aging more difficult and damaging for older gay men. One study found this not to be the case: older gay men reported an ideal body image greater than their actual BMI (Boisvert & Harrel, 2009). The thin body type and desire for a youthful appearance was relatively confined to younger gay men, which hints there may be a “double standard of aging” for men and women. Women experience harsh judgment when it comes to aging. Thus, more investigation must occur to determine if it applies to gay men (Boisvert & Harrel, 2009).
Ethnic and Racial Minorities
Ethnic minority men have also been highly ignored in terms of ED research. The little research that has been done regarding the topic was advised not to interpret their findings due to weak effect sizes (Wimbish, 2009). EDs within minority women vary from white women, as minority women are more likely to suffer from BED (Wimbish, 2009). Minority men have an array of vulnerabilities, as well as protective factors in developing an eating disorder. Men may attach different meanings to food, eating, and body ideals. Variety often accompanies different ethnicity or immigrant status (Boisvert & Harrel, 2012). Generally, African Americans have the second highest rate of being overweight and the highest rate of obesity. Among men, African Americans have the third highest rate for being overweight and the second highest in obesity second only to Mexican Americans. This increased risk of obesity could be a consequence of racial discrimination, lack of access to affordable health services, or poor health education. Overweight and obese African American’s are two to three times more likely to believe they are of average weight than their overweight or obese White peers (Wimbish, 2009).
Cultural weight differences and body image perception needs further research, though some experts believe that because of cultural acceptance for different body shapes and heavier weights, there is less pressure for an individual to lose weight through diet and exercise. Although the absence of desire to lose weight appears to be a protective factor, it may actually be a catalyst for disordered eating and body issues among African American men. A protective factor could be that African American men claim to accept their body type and weight more often than White individuals and larger body sizes do not significantly lower their self-esteem (Wimbish, 2009). However, along with Asian American men, African American men were more likely to induce vomiting than their white counterparts. Furthermore, there was a significant link found in between Black identity and a desire for muscularity (Wimbish, 2009). Onset can range from late teens though the thirties, but late onset could be attributed to individuals hiding their behaviors, leading them to remain undiagnosed or unreported (Wimbish, 2009).
As of now, treatment is relatively the same for men as it is for women, despite the different catalysts and outcomes that cause these disorders (William and Morgan, 2010). “Males are especially underrepresented in treatment seeking-samples, for reasons that have not yet been systematically examined” (American Psychiatric Association, 2013). Therefore, men may not be receiving the most effective treatment. For instance, to stop binge-purge episodes, women are often prescribed antidepressants (William and Morgan, 2010). But for men, it does not cease behavior as successfully. Behavioral relearning, which causes normalizing abnormal eating habits is important to treatment so patients cannot just “eat their way out of the hospital” to gain the weight needed to be released then go back to dangerous behavior (William and Morgan, 2010). The way men respond to treatment is overall less clear than the way women respond. Men have different perceptions of weight concerns and have higher rates of recovery if they are treated in separate programs using male clinicians. A focus on sexual identity also aided in recovery because the pressures men experience as gay makes relapse more likely if aftercare is not adequate (William and Morgan, 2010).
Both historically and presently, male-identified individuals with EDs have been overlooked, underdiagnosed, and under-researched due, in part, to the stereotyped belief that EDs predominantly manifest in White female-identified individuals. This stereotype results in an image of EDs that does not leave room for masculine identities and an erroneous assumption of symptom manifestation based on individuals who identify as female.
Across diverse and intersecting identities, individuals who identify as masculine experience unique social pressures of idealized body types for men, a connection between masculinity and body size/shape, and a stigmatization of help-seeking behaviors. For affectional minority men, ED symptoms are associated with both proximal and distal minority stress in the forms of internalized homonegativity and negative media portrayals/societal views, respectively. Further, historical contexts of the AIDS epidemic and the associations of “looking ill or weak” within the gay male community must be considered in the manifestation of EDs. For gender minority men and masculine-identified individuals, EDs may be complexly intertwined with societal pressures and expectations of their external bodies and their internal identities. EDs may develop in gender diverse masculine-identified individuals due to or in combination with gender-focused body dysphoria and the importance of gender affirmative treatment interventions cannot be overstated. Further research is needed to investigate the development of EDs in older adult men and, more specifically, in older gay men. In terms of race and ethnicity, more research is needed to better understand the impacts of systemic racism, stigmatization, and lack of access to resources in the development of EDs in African-Americans, Asian-Americans, and Mexican-Americans, as well as the cultural protective factors in both communities. Despite the clear differences in the prevalence, severity, and manifestation of EDs in masculine-identified populations, treatment is largely based on and designed for feminine-identified populations. The available research clearly indicates a need for gender-specific treatment for EDs.
Cite This Article
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