Weight History

One important distinction, in which men differ from women is their weight histories. Men frequently have been mildly to moderately obese at one point in their lives before developing an eating disorder, and were particularly susceptible if obesity was present in childhood. This contrasts with women as they generally felt fat before using compensatory behaviors to lose weight, however most women usually had a normal weight history (Andersen, 1999).

Compensatory behaviors, such as exercise, are also used more by men than women in order to avert the potential of developing medical complications that their fathers had developed. Most women do not use compensatory behaviors as a method of preventing the development of medical illness, but instead are founded on achieving thinness (Andersen, 1999).

The issue of weight concerns among males often is influenced by athletic achievement. More men than women are motivated to lose weight, or sometimes to gain weight, to achieve optimal performance in sports, and even in some cases, to be eligible to compete. This is also true in the cases of injury: resulting in attempts to avoid weight gain due to an inability to exercise (Andersen, 1999).

Sexual Abuse and Other Trauma

A literature review of the correlation between sexual abuse and eating disorders revealed that approximately 30% of eating disordered patients had a history of sexual abuse (Connors & Worse, 1993). For males, sexual abuse is likely underreported due to a disproportionate amount of shame and stigmatization that accompanies abuse for men versus women. Because of underreporting, there appears to be a smaller number of males with a documented history of sexual abuse. Most perpetrators of sexual abuse are males; therefore, males who are victims of sexual abuse may develop issues around sexual orientation and/or fear of experiencing sexuality. Through disordered eating, specifically anorexia, males struggling with these issues may deny natural hormonal mandates as a solution to their sexual orientation crisis, and therefore become asexual as a way to avoid sexual issues altogether (Morgan, 2008).

In Schwartz and Cohn (1996) it was reported that, “by the 1980s numerous publications found …1 in 3 females and 1 in 7 males [were victims of sexual abuse]” (p. x).

A major symptom of eating disordered individuals with a history of sexual abuse is body image disturbance. This suggests that addressing distorted body image is an essential aspect of treatment.

Physical and psychological traumatic experiences can vary in many ways, including childhood sexual abuse and childhood bullying. Childhood bullying is common in males, who may react to this trauma by conscious or unconscious manipulation of body shape. Generally this manipulation is focused on becoming more “masculine.” By becoming physically larger, men try to protect themselves from being an ongoing victim of aggression (Morgan, 2008).

Sexual Orientation

“Most men with body image disorders are straight and most gay men do not have body image disorders,” reports Morgan (2008, p. 64). With that in mind, symptoms related to eating disorder issues were found to increase 10 times more with gay and bisexual men than with heterosexual men (Strong, Williamson, Netemeyer, & Geer, 2000). Also, in a sample of 135 males with eating disorders, 42% of the bulimic patients considered themselves to be either gay or bisexual. In the same study, 58% of the men described themselves as “asexual” (Carlat, Camargo, & Herzog, 1997). Concern over body shape and weight is prevalent among homosexual males and can become pathological. However there are subcultures within the gay culture; not all of which stress body image. More heterosexual females struggle with body image concerns than gay males. Therefore being a gay male is not, in itself, predictive of males developing an eating disorder or muscle dysmorphia; however homosexuality is an indication for a male to be more at risk of developing a disorder (Morgan, 2008).

Some men, who experience confusion around sexual orientation, find comfort in weight loss as a product of restricted eating. In anorexia, severe weight loss creates changes in the body’s physiology, including lower testosterone levels, resulting for some, in asexuality. For some males, this sidesteps the issue of resolving sexual orientation conflicts by inhibiting libido all together. For these males, recovery can be difficult as the process of re-gaining weight reverses these physiological factors, thus re-starting puberty (Morgan, 2008).

Though few studies exist which have examined the influence of gender role orientation on disordered eating with males, there is evidence that men with “undifferentiated” and “feminine” gender roles have a higher prevalence of disordered eating than men with “masculine” and “androgynous” roles. Therefore it is recommended that professionals involved with treating disordered eating be aware of the influence of gender roles and gender differences in determining the presence or absence of disordered eating. It is also suggested that these influencing factors be addressed with distinctive approaches specific for males and females (Pritchard, 2008).

Depression and Shame

Males with eating disorders often experience depression and shame. “Hidden depression drives several of the problems we think of as typically male: physical illness, alcohol and drug abuse, domestic violence, failures in intimacy, self-sabotage in careers” (Real, 2003, p. 22), and now eating disorders are added to this list. In today’s world, men are expected to hide their vulnerabilities: including depression and shame which are associated with the stigma of being “feminine” (Real, 2003).

Underreporting of eating disorder symptoms (similar to what was mentioned previously about sexual abuse) is a major inhibitor to diagnosis, treatment, and accurate research for advancement in this area. The promotion of an accepted culture, which allows vulnerability in men may create an environment in which male reporting would improve in frequency and accuracy.

Exercise and Body Image

A frequent behavior among eating disordered men is excessive exercise; which can become “addictive” and is sometimes referred to as Anorexia Athleticism. Some men use exercise as a compensatory behavior for caloric intake; while others are caught in a vicious cycle of exercising for weight loss to promote better health, but find themselves in a “runaway diet,” resulting in self-starvation. Restlessness and physical over-activity result; as often seen in those with anorexia nervosa. Ultimately, other areas of the person’s life are affected, such as interference with work, social activities, or just meeting day-to-day responsibilities (Morgan, 2008).

Muscle Dysmorphia, rather than Reverse Anorexia Nervosa, is currently the preferred term for the disorder as it is not technically an eating disorder as Reverse Anorexia Nervosa implies. (The term dysmorphia is used in order to link the disorder to a more general diagnosis of Body Dysmorphic Disorder). In Body Dysmorphic Disorder, an individual is over-concerned, or obsessed, with certain parts of their bodies, in which they misperceive as being irregular or extremely unattractive. In Muscle Dysmorphia, a person is focused specifically on muscle mass or body size, making muscle dysmorphia a subtype of body dysmorphic disorder (Pope, Phillips, & Olivardia, 2002). However, in the proposed DSM-V diagnostic criteria for muscle dysmorphia, there is no mention of food and diet. There seems to be a considerable overlap between this disorder and an eating disorder. Many men who struggle with muscle dysmorphia, struggle with an eating disorder as well. It has been recommended that treatment interventions similar to those used for eating disorders be applied in cases of muscle dysmorphia (Morgan, 2008).

There is another aspect of substance abuse which is specific to males: the use of steroids and growth hormones. This is common when muscle dysmorphia is present. The rate of anabolic steroid use among young males is roughly equal to that of anorexia and bulimia in young females (Schooler & Ward, 2006.) Pope et al. (2002) state that over 2 million males of all ages in the United States have used anabolic steroids at some point. These drugs produce swift changes in muscle mass and have very few initial side effects for the user. However, long-term use has been linked with many physical and psychological complications. Some of these side effects produce prostate enlargement, high cholesterol, depression, and suicidal ideation as a withdrawal symptom (Mosley, 2008). Steroids and other hormones are often used by men with body image concerns, which are greatest for those with a less than average weight for height. These men generally have a high drive for bulk, paired with a high drive for thinness or lean body mass. As a result they are at risk for developing disordered eating habits such as bingeing, purging and restricting, along with the abuse of hormones (Blouin & Goldfield, 1994).

Comorbid Chemical Dependency

Past research reveals that people with eating disorders often struggle with comorbid psychiatric disorders such as substance abuse. A large number of studies have investigated this issue and found that people with eating disorders have a higher frequency of substance abuse than people who do not have eating disorders, and likewise, those who struggle with substance abuse disorders present a higher level of issues with food (Dunn, Larimer, & Neighbors, 2002). Other studies shows that roughly 24% of people struggling with bulimia also struggle with alcohol abuse or dependence (Costin, 2007) and that approximately 57% of males with binge eating disorder struggle with substance abuse issues compared to only 28% of females with binge eating disorder (American Psychiatric Association, 2006).

One connection to the use of substances is to control weight. Stimulants are increasingly used to manage weight. Unfortunately, it is common, while in treatment, for these individuals to be diagnosed strictly with a substance abuse disorder while their eating disorder is overlooked. Due to this tendency to under-diagnose, many individuals are only in treatment for substance abuse with little, if any, attention to food and body issues (Costin, 2007). It is usually recommended that individuals with the dual-diagnosis of an eating disorder and substance abuse be treated for the substance abuse primarily at the beginning of the course of treatment; as it is generally believed that it is ineffective to treat a person with an eating disorder while actively abusing an addictive substance. However, there is still very minimal information to recommend the best course of treatment; and it is possible that the most effective strategy would involve an intervention that includes both disorders (Mitchell, Specker, & Edmonson, 1997).