(Author, Department, University,
Corresponding Address and email)
Males may suffer from eating disorders and body image issues. Estimates show that more than 20% of patients with anorexia nervosa – a psychological disorder in which a patient thinks that he or she is too fat despite being emaciated – and bulimia nervosa – a disorder in which a person has alternative feelings of strong craving for food and aversion to food – are men. In men, patients with bulimia nervosa are more than the patients with anorexia nervosa. However, males have less inclination to bulimic compensatory behaviors such as laxative abuse or vomiting as compared to females, and they are more prone to use excessive exercise as a compensatory method of controlling weight and body shape. Studies are showing that in the present times, incidences of eating disorders are increasing in men or an increasing number of men has been identified to have these problems. However, men with eating disorders and body dysmorphia are often neglected in the diagnosis as well as treatment, and clinicians may also face the problem as a challenging situation (Strother, Lemberg, Stanford, & Turberville, 2012).
Eating disorders and muscle dysmorphia in the Diagnostic and Statistical
Manual of Mental Disorders, 5th edition (DSM-5)
In DSM-5, the diagnostic criteria for eating disorders were broadened, and researchers also included binge eating disorder as a kind of diagnostic entity along with anorexia nervosa and bulimia nervosa. This new entry in the diagnostic criteria helps in studying, eating disorders in males as the symptoms of eating disorders in males do not fit well into other categories that are mostly for females.
On the other hand, DSM-5 has considered muscle dysmorphia as a marker of body dysmorphic disorder. Symptoms for muscle dysmorphia include disturbance in body image; comorbid personality traits; disordered eating, and anxiety or affective disorders along with eating disorders, and similarity of the problem with anorexia nervosa (Raevuori, Keski-Rahkonen, & Hoek, 2014).
Prevalence of eating disorders
It has been reported that the lifetime prevalence of bulimia nervosa in males may range from 0.1% to 0.5%; of anorexia nervosa may range from 0.16% to 0.3%, and of binge eating disorder may range from 1.1% to 1.3% in males. Eating disorders are more prevalent in females as compared to males. The rate ratio of lifetime prevalence of anorexia and bulimia nervosa in males as compared to females would be 1:10. However, there are higher levels of variations for anorexia nervosa, i.e., 1:3 to 1:12, and for bulimia nervosa, i.e., 1:3 to 1:18, as compared to binge eating disorder, i.e., 1:2 to 1:6 (Raevuori, Keski-Rahkonen, & Hoek, 2014).
Recent studies show that the prevalence of “any DSM-5 eating disorder” in men is about 1.2% at the age of 14 years, 2.6% at the age of 17 years, and 2.9% at the age of 20 years. The prevalence of bulimia nervosa in males is reported to be 0.4% at the age of 14 years, 0.7% at the age of 17 years, and 1.6% at the age of 20 years. However, researchers are of the opinion that prevalence studies would need further investigation as the percentages and rate ratios of eating disorders in males could be clinically at an underreported level (Raevuori et al., 2014).
Issues that may result in eating disorders
Several issues are found to be related to eating disorders and body dysmorphia in men. These issues may include gender orientation, media, body and muscle image, and sexual abuse and other such trauma (Strother et al., 2012).
Gender orientation
Body dysmorphia and eating disorders can be most frequently found in homosexual and bisexual males as compared to heterosexual males. It has been reported that homosexual and bisexual males have nearly 10 times more chances of developing issues of eating disorder. In a study of 135 males having eating disorders, it was reported that 42% of the patients with bulimia nervosa considered themselves as either gay or bisexual. In the same study, 58% of the males reported themselves as bisexual (Strother et al., 2012).
Issues of body image and eating disorder in homosexual males can become pathological in certain cases. However, some males, even in gay culture, do not stress body image. Moreover, the number of heterosexual males having body image issues is more than homosexual males. Therefore, homosexuality in males would not be an ultimate marker of developing an eating disorder or body dysmorphia, but it can show that they have increased chances of developing such issues (Strother et al., 2012).
Research also shows that men with confusion about sexual orientation may also find comfort in weight loss with the help of restricted eating. In anorexic conditions, extreme weight loss can change the physiology, thereby affecting the testosterone levels leading to asexuality. This decrease in testosterone levels helps in resolving the confusion of sexual orientation by decreasing libido altogether. Those males may again face the problems of sexual orientation when they start gaining weight (Strother et al., 2012).
Gender role orientation can also influence the eating disorders and body image issues in males. Males with “feminine” and “undifferentiated” gender roles have more chances of developing eating disorders as compared to males with “masculine” and “androgynous” roles. However, further studies are required in this regard (Strother et al., 2012).
Body and muscle image
Body Dysmorphic Disorder (dysmorphia) is a condition in which a person is very much concerned, or obsessed, with some parts of the body, which he or she thinks to be irregular and/or extremely unattractive. People may also develop muscle dysmorphia in which they start showing extreme concern about muscle mass and/or body size, therefore, it can be considered as a subtype of dysmorphia. Although DSM-5 diagnostic criteria are not showing food and diet problems in muscle dysmorphia, but there is a significant overlap between these problems and eating disorder. Therefore, most of the males with muscle dysmorphia may also suffer from the problem of eating disorder (Strother et al., 2012).
Males with muscle dysmorphia may also start showing increased use (abuse) of steroids and/or growth hormones. Reports show that the rate of the use of anabolic steroids in young males is almost equal to that of young females having the issues of anorexia and bulimia nervosa. Males with body image issues and having less than average weight for height have more chances of using steroids and growth hormones. These males often try to motivate themselves to improve their body weight or lean body mass, and eventually develop disorders in eating habits such as purging, bingeing, and restricting (Strother et al., 2012).
Media
Media has played a very important role in changing the perception of body image, thereby affecting the eating disorders. The analysis shows that the frequency of images of semi-naked men in media has increased in the past 3 decades. Moreover, popular culture has started showing increased interest in muscularity. After looking at these so-called ideal bodies, males may start excessive exercise and use steroids. Male body image ideals have also significantly affected the eating habits and body images (Strother et al., 2012). Considering these things, it is easy to guess that media can also significantly influence the thinking of homosexual males, and males having “feminine” and “undifferentiated” gender roles.
Sexual abuse and other such trauma
Reports show that about 30% of the patients with eating disorders had a previous history of sexual abuse. However, for males, sexual abuse is likely to be underreported as it is related to high level of stigmatization, so the number of males having a history of sexual abuse is small. Most of the times, perpetrators of sexual abuse are males, so males having a history of sexual abuse may also develop issues related to sexual orientation. With the help of disturbed eating, particularly anorexia, males having these issues of sexual orientation try to reduce their problem as they may develop hormonal issues, and sometimes they may also become asexual. Body image disturbance is also a major symptom of patients with eating disorder having a history of sexual abuse (Strother et al., 2012).
Physical as well as psychological trauma including bullying experienced by males in their childhood may also result in eating disorders and body image related issues. Usually, males with childhood bullying, consciously or unconsciously, start considering the manipulation of their body to become more “masculine” as they think that a physically larger body could help them in getting protection from others (Strother et al., 2012).
Clinical assessment of males
Hospitalized males having a severe problem of anorexia nervosa, usually, has higher ages (i.e. Averaging 20.8 years) as compared to females (i.e. Averaging 18.1 years). Moreover, males have higher levels of body mass index (BMI) as compared to females. Males may show better recovery from anorexia nervosa as the duration of hospitalization in males for this condition is shorter than females. Males also show fewer suicide attempts as compared to females in anorexia nervosa. Males also report less anxiety, obsessive-compulsivity, somatization, and interpersonal sensitivity (Raevuori et al., 2014).
Therapeutic strategies for eating disorders and body image issues
Researchers are of the opinion that males would show better outcomes after using therapeutic strategies due to their increased ability to “fix” the problems as compared to females. In order to deal with body image issues, health care experts may start considering muscle dysmorphia that is more prevalent in males. Males with such disorders can be taught that they have to give more importance to their qualities rather than their appearance, i.e. health care experts have to change their understanding of masculinity. Moreover, health caregivers have to consider all the issues such as gender orientation, sexual abuse, traumatic experiences in childhood, media pressures, and weight history, before starting an intervention. These interventions may include the therapeutic strategies that are commonly used for women along with evidence-based modalities including dialectical behavior therapy, cognitive behavior therapy, and other such psychotherapeutic methods (Strother et al., 2012). However, further studies are required to design appropriate therapeutic strategies for males.
Concluding Remarks
Male eating disorders and body dysmorphia are among those psychopathological issues that are different from those found in females (Dakanalis & Riva, 2013). Usually, males with eating disorders and body shape issues have a desire to gain weight, whereas few of them have a drive of thinness. However, presently, most of the studies focus on females, so further studies are required on the eating disorders and body image dissatisfaction levels in males.
Research is clearly showing that the factors leading to body image issues and eating disorders in males are different from those of females, and these differences can be found in predisposing, perpetuating, and precipitating factors. Predisposing factors include the factors that may increase the chances of developing psychological problems; perpetuating factors are those factors that are involved in maintaining the psychological problems and preventing their resolution, and precipitating factors are those factors that may start or exacerbate the psychological problems. Detailed study of these factors can help in improving the diagnostic criteria and therapeutic interventions. Studies on these factors can also help in improving the effectiveness and validity of body image assessment scales for males.
Sometimes healthcare experts fail to diagnose eating disorders in males or they are slow in finding the basic problem. Healthcare experts have to consider that the symptoms of eating disorders and body dysmorphia could be different in males as compared to females, and most of the eating disorder instruments are designed for females. Therefore, it is important to raise awareness of eating disorders in males and to develop and validate instruments that would help in the assessment of the symptoms of their eating disorders, so that it would be easy to identify the problem and seek help before the issue becomes serious.
References
Dakanalis, A., & Riva, G. (2013). Current considerations for eating and body-related disorders among men. Handbook on body image: Gender differences, sociocultural influences and health implications, 195-216.
Raevuori, A., Keski-Rahkonen, A., & Hoek, H. W. (2014). A review of eating disorders in males. Current opinion in psychiatry, 27(6), 426-430.
Strother, E., Lemberg, R., Stanford, S. C., & Turberville, D. (2012). Eating disorders in men: underdiagnosed, undertreated, and misunderstood. Eating disorders, 20(5), 346-355.
