Does Gender Matter In Eating Disorders?

For years, eating disorders were seen as a female problem. Now we know that males also suffer from eating disorders, accounting for up to 25% of all cases of anorexia and bulimia and an even larger percentage of cases of binge-eating disorder.

Does treatment differ between males and females with the same eating disorder?

Yes and no. Regardless of gender, identifying individuals at risk and diagnosing those with eating disorders as soon as possible contributes to significantly better outcomes. Normalizing eating becomes the next imperative with a goal of stabilization. Physicians and therapists then work with the individual to understand the motivation for the eating disorder, challenge thoughts related to weight and shape, adopt new behaviors, develop self-worth, engage in new thought patterns, and build sustainable support systems.

Within those common steps, however, gender distinctions affect the therapeutic approach. In screening, for instance, physicians, dieticians, and others may readily recognize extreme dietary restriction, rapid weight loss, vomiting, and laxative or diuretic use as signs of eating disorders in girls and women. Fewer think to associate a young man’s body-building program, low-fat diet, protein shakes and supplement use with a potential eating disorder. Consequently, boys and men are referred for treatment at lower rates and later in the development of their disorder.

Amenorrhea often triggers further investigation into a teenage girl or woman’s eating and exercise habits. No such obvious signal exists for men, though loss of bone and muscle mass as well as sex drive typically happens more quickly for males than females. In the early stages of eating disorders, women continue to have sufficient estrogen to protect their bones longer.

Help in making a diagnosis

Research indicates that for these reasons and others, eating disorders remain underdiagnosed and undertreated in males. One useful screening tool is the Eating Disorder Assessment for Men (EDAM), developed by Stanford and Lemberg. EDAM identifies four primary domains for diagnosis: binge eating, muscle dysmorphia, body dissatisfaction, and disordered eating.

Both males and females with eating disorders typically have a distorted sense of their bodies. While most individuals with eating disorders think they are much larger than they are, females tend to think they are overweight even when within or below the normal range, whereas men more often start out overweight or obese. For women, the goal is to be thin. For men, it is often to be lean.

Just as girls and women in certain sports — gymnastics, dance, cheerleading, crew and track — may initially start dieting to achieve their view of the sport’s ideal physique, boys and men in wrestling, track, bodybuilding, gymnastics, basketball and horse racing may begin a diet and exercise program in response to actual or perceived pressure from coaches and teammates.

A significant proportion of men with eating disorders, however, feel they have insufficient muscle mass to meet their preconceived standards of masculinity. This concern can become muscle dysmorphia, which may lead men and boys to see themselves as significantly smaller than they are. The desire to increase muscle mass can lead to excessive strength-building exercise, disordered eating and steroid abuse. Research by T.E. Weltzin and others suggests that steroid abuse may serve the same compensatory function for men and boys with eating disorders as vomiting does for women and girls.

Therapists can help males with this issue work toward a broader understanding of masculinity that includes personal qualities and supports a sense of self-worth apart from size and physique. The desire to build a stronger body can provide leverage to help men and boys with eating disorders adopt healthier eating and exercise patterns.

Getting a patient to take that first step

Because males do not seek treatment as often for eating disorders — or any mental health issue — men may feel uncomfortable admitting they have a problem or engaging in therapy. Acknowledging that entering into therapy is an important step in taking control of their lives and their health can help males in particular see treatment more positively as it appeals to the need to control themselves and their environment characteristic of many individuals with these issues. Women and girls generally feel more at ease sharing their experiences and supporting each other in group therapy, a common mode of treatment, once a sense of safety has been established but still experience concerns about losing control by entering treatment.

For males suffering from anorexia nervosa who have lost substantial weight, their generally larger size will dictate a need for more nutrition, even at the beginning of treatment. Those with muscle dysmorphia will need help preparing for and accepting the loss of muscle mass that will likely accompany a substantially reduced exercise program and weaning from steroids, if they have been used to adding bulk. Both men and women who have used excessive exercise to lose weight or maintain an otherwise unsustainable weight will need to develop alternative outlets that provide positive reinforcement for healthy behavior, fill the time previously occupied by exercise, and support feelings of self-worth.

For males and females, the most important step in treatment is getting started. Primary care physicians, pediatricians, dieticians, coaches and others can help by recognizing the different symptoms and motivations between the genders and referring both for therapy as early as possible.