EATING DISORDERS IN MALES
Miles E. Drake, Jr., M.D.
Eating disorders are predominantly diagnosed in females, especially young women, although the current diagnostic criteria for anorexia and bulimia nervosa make no specification as to gender (American Psychiatric Association, 2013). They are also relatively recent disorders, having been described clinically only in the 19th century, possibly because of the importance of having enough to eat through most of history and the relative difficulty for most people of eating too much through much of that time. There have been reports of disordered appetite for centuries, however, and early descriptions of eating disorders did on occasion include males.
Anorexia is found through much of history usually in relation to religion, with many cases of fasting in preparation for some observance, duty or special message. Eastern cultures tended to fast longer, sometimes as an ultimate form of withdrawal from worldly influences and pursuits, and such fasting sometimes persisted unto death (Bemporad, 1996). Some ancient cultures were more comfortable than modern ones with eating behavior that would today be considered binging and purging, most notably the Romans, although historians now believe that the celebrated term vomitorium did not refer to a chamber designed for evacuation during banquets, but rather to a passageway to “spew forth” crowds from an arena or theatre. Egyptian medical papyri prescribed feeding alternating with purging for certain disorders, and the Talmud described periods of ravenous appetite for which sweet foods known as bolmoot should be given (Gordon, 2000).
Medieval Christianity considered anorexia to be a form of asceticism and honored some, especially women, who starved in order to control the body in the service of God; a prominent example was St. Catherine of Siena, who stated that her legendary fasting was “an infirmity” and could not eat even when ordered to by her confessor and the Pope. Such fasting was not confined to women, and male examples include Saints Gregory, John Chrysostom, Alphonse de Liguori and Robert Bellarmine, although asceticism was not favored after the 16th century (Brumberg, 2000).
Medical study of anorexia began in 1689 with Richard Morton’s Phtisologia, a treatise on consumption that described two cases of wasting away, one of them male. Profound emaciation in men as well as women was described in several texts between 1700 and 1860. Anorexia was initially classified as a form of consumption, but came to be associated with hysteria, an almost entirely female umbrella term for mental disorder. Anorexia nervosa was differentiated from hysteria by Sir William Gull, the physician to Queen Victoria who has been occasionally suggested to have been Jack the Ripper, and in this report the infrequent occurrence of the disorder in males was noted, although the two cases described were females (Hepworth, 1999).
Because of the historical preponderance of women and the association with hysteria, it is likely that eating disorders in males are underdiagnosed. Recent studies suggest that men comprise about 10 per cent of anorexia and bulimia patients, usually presenting in adolescence (Carlat, Camargo & Herzog, 1997). Binge eating disorder is equally distributed between males and females, and usually presents in adulthood with the complications of obesity (Striegel-Moore & Franko, 2003).
Eating disorders in both sexes are correlated with anxiety, chemical dependency and depression. Men who scored high on a self-report measure of eating disorder had a two-fold increase in likelihood of comorbid substance abuse, particularly of drugs with appetite-suppressing properties like cocaine or stimulants (Gadalla, 2008). Anxiety was considerably more common (4.6 times) in Canadian men with anorexia, bulimia or binge eating. (Gadalla & Piran, 2007).
A strong desire to control weight through dieting and idealization of a particular body habitus is common to males and females with eating disorders, but the ideal body state may differ between the sexes. There is a strong association between eating disorders, competitive sports and extreme exercise among men, particularly those sports which require low body weight or body mass index. Male elite athletes in Norway were twice as likely to have eating disorders as the general male population, and the risk was particularly high in those sports which required performance against gravity, such as the pole vault or the high jump (Sundgot-Borgen & Torstveit, 2004). Male and female triathlon participants scored higher than the general population on measures of disordered eating (DiGioacchino de Bate, Wethington & Sargent, 2002), and some but not all French male high-performance cyclists manifested eating disorders, the principal predicting factor being perfectionism (Ferrand & Brunet, 2004).
Both males and females are concerned with body image, but the preferred body image among present-day females is thin, while the preference among men is for muscularity (Edwards & Launder, 2000). Various cultural and media influences have been suggested as causes for increasing male preoccupation with muscular development and body building (Leit, Gray & Pope, 2002). When men with anorexia or bulimia, athletic men and nonathletic controls were compared as to body habitus preferences and their perceptions of their own bodies, there was little difference between the groups as to preferred and perceived muscle mass, but anorexic and bulimic men perceived themselves to have twice as much body fat as they actually did (Mangweth, Hausmann, Walch, Hotter, Rupp, Biebl, Hudson & Pope, 2004).
The preoccupation with muscularity and body fat may account for a greater predilection for pathological exercise in men with eating disorders. An increased incidence of addictive exercise behaviors has been found in male anorexics and bulimics: loss of control of exercising, increased tolerance for exercise and particularly endurance exercise such as running, reduction in or avoidance of alternative activities, exercising even when ill or injured, distress when unable to exercise as desired and exercising in isolation or in secret (Hausenblas & Downs, 2002). An unbalanced approach to exercise is characteristic of men with eating disorders: incremental reduction of calorie intake over time, with a particular avoidance of fats and eventually carbohydrates, and emphasis on calorie-burning exercise, rather than maintenance of muscle mass and strength. This is thought to trigger excessive exercise and purging, on account of fear of increased body fat, when attempts are made to increase food intake (Weltzin, 2012).
Homosexuality is a risk factor for eating disorders in men. Homosexual men are more often diagnosed with eating disorders (Russell & Peel, 2002), and have higher levels of anxiety about body image, expressed body image concerns, sensitivity to media and cultural influences regarding the body and measures of eating psychopathology than heterosexual men (Carper, Negy & Tantleff-Dunn, 2010). Younger homosexual men (Boisevert & Harrell, 2009) and men with gender identity disorders (Hepp & Milos, 2002) are more likely to have anorexia or bulimia. It has also been suggested that peer pressure regarding body habitus is greater in the gay culture (Hospers & Janson, 2005).
Other risk factors more prominent in male eating disorder than among females are past weight problems, bullying on account of weight, physical abuse and alcohol abuse. A large French series of severe anorexic patients (Gueguen, Godart, Chambry, Brun-Eberentz, Foulon, Divac, Guelfi, Rouillon, Fallisard & Huas, 2012) found that males were much more likely to have been overweight in the past, and to have been victimized on account of their weight. Alcoholism and past physical abuse were also correlated with male anorexia (Johnson, Cohen, Kasen & Brook, 2002) or binge eating (Womble, Williamson, Martin, Zucker, Thaw, Netemweyer, Lovejoy & Greenway, 2001).
Treatment and Prognosis
Men and women with eating disorders apparently have similar and generally favorable responses to treatment (Bean, Loomis, Timmel, Hallinan, Moore, Mammel & Weltzin, 2004). Treatment plans generally address psychiatric comorbidity and past traumatic experiences related to weight, identify and challenge thinking errors about food and weight and set nutritional goals intended to normalize weight, increase food intake and reduce abnormal food-related behaviors. Excessive and abnormal exercise must also be addressed in many male patients. A gradual weight-gain program with limitation of exercise during this period is generally recommended, along with nutritional education to overcome aberrant beliefs about food and eating. Male patients who are significantly underweight are at risk for hypothalamic hypogonadism and osteoporosis, and measurement and correction of serum testosterone is also helpful (Mehler, Sabel, Watson & Andersen, 2008). Cognitive behavioral therapy is effective in challenging erroneous thinking about food and exercise, and is also useful for comorbid anxiety and affective disorders. Men with eating disorders are reported to be uncomfortable talking about feelings and life experiences, and to externalize emotional distress; there is also frequent reluctance to discuss a problem that is widely viewed as “female,” and all-male therapy groups are recommended for these reasons. Family therapy to encourage appropriate emotional expression and experiential therapy such as art, movement and recreation to address body image and exercise issues are also increasingly used (Darcy, 2011). Recent studies have suggested that the leading obstacles that must be overcome for earlier diagnosis and institution of generally effective treatment of eating disorders in male patients are lack of awareness that men can have eating disorders and the perception among men that having an eating disorder is very stigmatizing (Robinson, Boache & LaFrance, 2012).
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