Most of what we know about eating disorders is based on what we know about women with eating disorders. Most of what we know about men with eating disorders is based on what we know about conventional models of masculinity. Most of what the two of us know about either of these topics is heavily influenced by our own gender, sexual identities, and ethnic backgrounds. These are the limitations that we, as psychotherapists, bring to the room when working with males- an underserved population in the world of eating disorder treatment. By examining the differences and similarities between how males and females with eating disorders present clinically we hope to shed some light on issues to be aware of as clinicians and how we can move towards a more comprehensive treatment of the eating disorder population.
Conventional wisdom tells us that one in ten people with eating disorders are male, but data suggests that 25% of diagnosable cases occur in males and that males have higher rates of disordered eating (Hudson et al., 2007). As is, unfortunately, easy to imagine, it is suggested that under reporting is a result of stigma, lack of sensitivity and detection, and gendered perceptions of eating dieting. The lower occurrence of eating disorders in males may, however, also be attributed to gendered differences in the risk and maintaining factors for eating disorders .
A difference in biology, brain organization and temperament, for example, are factors that appear to insulate men against risk. Mood disorder vulnerability also seems to put males at a lower risk as they have a greater tendency towards externalization as opposed to the female tendency for internalization- a trait that can serve as fuel for the eating disorder. Generally speaking, men present with less harm avoidance, less drive for thinness, and less body dissatisfaction; with what we know about eating disorders, this discrepancy should also account for the lower prevalence in the male population. That being said, it falls on us, as clinicians, to make sure we bring a certain awareness of clinical features and differences into our female-normed assessments to work against the risk of underestimating rates and severity.
One feature that is similar in both women and men with eating disorders is that men with ED present differently than men without ED- they may be struggling with depression or other impairments. The many ways that males and females differ in eating disorder presentation, however, lie in the manifestation of the illness; for that reason, it is of the utmost importance that we, as clinicians, maintain an acute awareness of our language during assessment. It is not as pertinent, for example, to assess for a “fear of fat” with a male client as males tend to idealize a body that has less fat and more muscle, therefore they tend to fear “softness” rather than “fatness”. A preoccupation with the need to be “lean” might be more relevant to males with eating disorders rather than the drive for “thinness” often seem in females. Additionally, males with eating disorders may present with use of steroids and human growth hormone. These factors are all important when assessing males on a drive for muscularity scale, male body checking scale, and obligatory exercise scale.
In addition to maintaining awareness in assessment of males, it is equally critical to maintain acute awareness of the language we use in the treatment of males. For a clinician accustomed to treating females, it is likely common to use very emotionally charged language such as “opening up”, “sharing”, and even referring to “fat as a feeling”. Not only are men generally less familiar with eating disorders than women, for better or for worse, men have been socialized by an unspoken male code to not be weak or vulnerable and to prioritize leadership, work, and self-sufficiency. While it is an adjustment from the way we work with female clients, it does not have to be an obstacle in helping our clients. Instead, we can work with decisional balance- weighing the pros and cons of change versus the pros and cons of no change with our male clients. By leaving what works for female clients at the door, we serve our male clients better and respect their sense of masculinity- however that may look for any one individual.
As individuals working with an already stigmatized disorder, it is important to constantly learn and keep an open mind and consider how much additional bravery it takes for a minority of an affected population to seek out our help. While we have made great strides in the treatment of eating disorders, there is always room for improvement. By embracing the difference in our experience as treatment providers, we will be able to work more successfully with this underserved population and further contribute to the work we all do to counter eating disorder stigma.