I recall the day in September 1993 with precise detail. I had come back from class and my answering machine tape was full of voicemails from college men around Massachusetts who struggled with eating disorders. They graciously thanked me for investigating the understudied group and expressed interest in participating. They viewed the advertisement I placed in their college newspaper looking for men who struggled with anorexia nervosa, bulimia nervosa, and binge eating disorder (at that time called eating disorder not otherwise specified) for my senior honors thesis at Tufts University. My thesis committee wanted me to have a Plan B topic just in case I was not able to get enough men, due to low prevalence or lack of disclosure. No Plan B was needed. There were many men who were secretly struggling- emphasis on the word “secretly”. In fact, I was the first person that most of the men had told about their tormenting relationships with food and their bodies. There were men in therapy for depression, substance abuse or anxiety, but never disclosed to their therapist that they were painfully dealing with an eating disorder for fear that they would be perceived as disturbed, less masculine or have their sexuality questioned.
Today, the cloud of shame for men with eating disorders still exists, although the visibility and access to resources is much better. The truth is males make up as many as 1 in 4 people who suffer from eating disorders, yet men make up approximately 1 in 10 eating disorder patients. Many men are still in the shadows not getting the treatment they desperately need. When my co-authors and I wrote “The Adonis Complex” in 2000, we wanted to bring attention to this population, making it okay for men to shed the shame and stigma of struggling with something that was only perceived as affecting women.
Whether it’s casual conversation or a professional talk, people are still in disbelief when I tell them that I specialize in the treatment of boys and men with eating disorders. “I didn’t even know anorexia existed in boys”, a neighbor exclaimed. Boys and men are dying, literally, for visibility. My male patients want myths dispelled and truths clarified. I asked them what they would want people to know, as I prepared for writing this blog. Here are some of those statements:
“Not all men with anorexia want to be skinny and fear being fat. We want to be lean and muscular.”
Most of the boys and men I have treated for anorexia or restrictive eating do not always present in the ways we might be accustomed to with female patients. Most of my male anorexic patients know they are emaciated and often think they look terribly unhealthy. They do not aspire to be skinny, but want to be lean. The problem is that to gain muscle, you must have fat first. Patients fear they will gain weight and it will not be muscle weight, so they are stuck in this conundrum of starving themselves.
“Having an eating disorder disconnects me from my own humanity.”
An existence devoid of food and nourishment is both a literal and spiritual emptiness. The further one gets embedded in an eating disorder, the more one disconnects from everything that made them feel connected and grounded in the world, making it harder and harder to even recognize what it is worth fighting for in recovery.
“Not all of us are gay or struggling with our sexuality.”
Contrary to research done in the late 1970’s and 1980’s that always equated eating disorders in men to a homosexual orientation, most men with eating disorders are heterosexual. To simply focus on sexuality can undermine the complexity of factors or comorbid disorders that contribute to an eating disorder, including depression, trauma, poor self-esteem, obsessive-compulsive disorder, ADHD, and/or fears of maturity.
“There are issues unique to gay men and eating disorders that should be considered.”
Gay men may suffer from body image problems for unique reasons that do not affect heterosexual men. One patient who was bulimic and a compulsive weightlifter discussed how his body image obsessions began in early adolescence after being physically assaulted many times for being gay. He saw a muscular body as being a symbol of threat to ward off homophobic attacks. Another patient of mine said that his anorexia started at the age of 13, when it was evident that he was gay. He felt it was a lot easier to obsess about food than think about sex. The side effect of testosterone decline, resulting in a loss of libido, was a bonus for him, as he sought to deny and escape from his gay identity.
“It is not just about weight. Guys obsess about other body parts.”
Body Dysmorphic Disorder (BDD) often accompanies eating disorders. BDD affects men and women equally, although men are often underrepresented in treatment centers. BDD is a preoccupation with an aspect of appearance that one sees as ugly or deformed, when it fact it looks fine. Men I work with obsess about their hair, eyes, skin, penis size, muscle mass, and height among other things. BDD is a tormenting disorder that has sufferers obsessing about their “ugliness” and engaging in rituals around their appearance. Cosmetic surgeons may see these patients before therapists do, since patients believe the only effective treatment is changing the body part. (This does not help BDD and often makes it worse).
“Please take it seriously.”
This statement is from a 52-year-old patient who almost lost his life, twice. He almost died of cardiac arrest at the age of 14 due to severe anorexia and purging behaviors. He never got the treatment he needed because his family thought he was just doing it for attention and his parents did not take his battle seriously. At 40, he attempted suicide because waking up every morning meant hours upon hours of thinking about what to eat and what not to eat and whether he looked acceptable to leave the house. He felt too ugly to live. His family and even a previous therapist (who was ill informed about eating disorders) said he was either being dramatic or was seriously psychotic because “you just don’t see this in men, and certainly not in older men.”
“There are negative cultural messages fed to guys about how to act and what to look like.”
Boys and men are fed a diet of media imagery of being muscular, having a perfect six pack of abs, strong jaws and big bulges. This is coupled with masculine scripts of never crying or being weak. Open up any magazine and you will see underwear ad models sporting rock hard abs, supplements meant to enhance muscle mass, as well as ads telling men that cosmetic surgery is not just for women. Combine all that with the impact of social media and you have a recipe for body dissatisfaction Being an adolescent boy today is much harder than when I was a teenager in the 1980’s (and that was tough enough).
I wish for one day to try to recruit subjects for a study of eating disorders in males (and females) and find I need a Plan B topic, simply because the problem is not affecting people out there. In the meantime, we have much work to do.
This blog was written by Roberto Olivardia, Ph.D., Clinical Instructor of Psychology at Harvard Medical School and Clinical Associate at McLean Hospital in Belmont, Massachusetts. He has been researching and treating boys and men with eating disorders for over 20 years. He maintains a private psychotherapy practice in Lexington, Massachusetts.