Men, Eating Disorders, And Why Gender Matters

Eating disorders are complex, multi-faceted conditions involving biological, psychological and sociocultural factors: gender provides us with an analytic lens through which these different components can be understood.
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The recent episode of BBC One Panorama, "Men, Boys & Eating Disorders", and news reports on NHS figures that show the number of men being admitted to hospital with an eating disorder has risen by 70% over the past six years, and those referred for treatment has risen by more than 40% in the past two years, have sent a definitive message that yes, men get eating disorders too. Historically, eating disorders have not received the same amount of attention as other mental health issues experienced by men, such as depression, suicide and substance abuse, and gender bias around eating disorders continues to be a barrier to recognizing the symptoms for both sufferers and healthcare professionals. The sharpened focus on how men specifically are affected by eating disorders is a vital step towards improving understanding, identification and treatment of eating disorders in men as a social group. However it also provides a useful starting point for taking a differentiated approach that considers how all aspects of an individual's identity and situation - including, but not limited to gender - shape their experiences with eating disorders.

Some advocates, however, have reasoned that since eating disorders affect men as well as women (and trans folk and people of all gender identities, for that matter), gender is not a relevant factor. For example, a spokesperson from leading eating disorders charity, Beat, made the argument, "while people with eating disorders can be diagnosed with various illnesses, including anorexia, bulimia, binge eating disorder and OSFED (other specified feeding or eating disorder) - and can have a wide range of psychological, behavioural and physical symptoms - these aren't likely to differ hugely on account of gender". The spokesperson added, "it's vital that everyone is aware that eating disorders can affect anyone, and gender is not a factor".

Whilst it is certainly the case that eating disorders can affect anyone irrespective of their gender, female gender is a significant risk factor as eating disorders continue to disproportionately affect women (9 in 10 cases are female) even as the number of men diagnosed rises at rates comparable to those of women. Current figures likely underestimate the prevalence of men with eating disorders, however gender is relevant to understanding the statistical reality as health professionals' beliefs about who is affected by eating disorders, stigma associated with coming forward as a man with an eating disorder, and gender bias in assessment tools all contribute to the under-diagnosis of eating disorders in men. Gendered constructions of eating disorders as a female problem may be responsible for delays in men seeking treatment, and this is corroborated by research exploring how social norms of masculinity shape men's help-seeking behaviours across a range of physical and mental health contexts.

Masculine ideologies that emphasise the importance of physical strength, rationality, self-reliance and emotional repression are incongruent with the stigmatized, feminized characteristics commonly (yet incorrectly) attributed to people with eating disorders, such as superficiality, vanity, physical frailty and emotionality. These stereotypes negatively impact both men and women, and are enmeshed in systems of power and privilege that uphold social norms of masculinity and femininity relating to mannerisms and body ideals. A 2015 study of 246 young heterosexual men found that increased conformity to masculine gender norms predicted greater muscle dissatisfaction and muscularity-oriented disordered eating. Early research suggested that gay men may be more likely than heterosexual men to experience thinness-oriented eating disorders, however contrasting findings support an increased drive toward both thinness and muscularity in gay men.

Homosexuality is recognised as a specific risk factor for eating disorders, and recently, international rugby union referee, Nigel Owens, and lead singer of the band Years and Years, Olly Alexander, shared their experiences with eating disorders in the context of struggling to come to terms with their sexuality in the BBC documentaries "Men, Boys & Eating Disorders" and "Olly Alexander: Growing up Gay" . Whilst gay men are thought to represent 5% of the total male population, research suggests 42% of men with eating disorders identify as gay. Moreover, a study of over 289,000 students from 223 US universities found that transgender college students are almost five times as likely to experience an eating disorder than cisgender students, and cisgender sexual minority men and women were two to four times more likely to have been diagnosed with an eating disorder than heterosexual men and women.

Eating disorders in the LGBTQ community need to be understood within the broader cultural context of oppression. Although belonging to a gender or sexual minority group is a risk factor for eating disorders, it is not causal of eating disorders. Instead, experiences specific to these groups, such as homophobia, transphobia, bullying, harassment and violence, as well as body ideals specific to the queer community, may contribute to the development of eating disorders. What's more, a lack of gender-appropriate and culturally competent treatments that address issues relating to sexuality and gender identity may pose significant barriers to recovery. For example, many medical professionals endorse a version of eating disorder recovery that entails rejoining "normative developmental trajectories" - a concept that contains heteronormative assumptions about the kinds of bodies, desires and ways of living that signal "recovery", which may inadvertently pathologize queerness. It is important that the medical community not only works to identify eating disorders in men of all sexual orientations and gender-diverse people, but also that it affirms diverse forms of recovery, supporting people to recover in ways that are consistent with their identity and values.

Athletes represent a subset of men at increased risk for eating disorders and disordered eating and exercise behaviours. Eating disorders may present differently in athletes, with symptoms such as dangerous weight-cycling behaviours, disordered eating directed towards either weight loss or gain, misuse of steroids or performance-enhancing drugs, excessive exercise or exercise dependence reflecting the requirements of particular sports. Different sports, as well as different training environments, confer different levels of risk, with high-risk sports falling into the same categories as with female athletes: aesthetic sports (e.g. bodybuilding), sports in which maintaining low body weight or body fat is considered advantageous for performance (e.g. endurance sports such as cycling and long-distance running), and sports in which there is a need to 'make weight' (e.g. boxing, powerlifting, rowing, and horse-racing).

Rowing provides an example of a sport that allows comparison of male and female athletes and where some athletes (lightweight rowers) must meet specific weight criteria, whilst others do not (heavyweight rowers). In a comparison of male and female lightweight and heavyweight rowers, male rowers were more affected by weight restriction than were female rowers, with the lightweight rowers specifically showing greater weight fluctuation during the competitive season, and gaining more weight during the offseason, than both the lightweight females, and heavyweight male and female categories. In females, the Female Athlete Triad is defined as the interrelationship of low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density most commonly seen in female runners, however analogous processes involving impaired nutrition, hormonal dysfunction and low bone mineral density have also been observed in a subset of male athletes. Developing diagnostic tools and criteria appropriate to this population is an important task for researchers working at the intersection of eating disorders and sports.

There is ongoing debate as to whether muscle dysmorphia - a form of body dysmoprhic disorder that manifests as disturbances in body image relating to muscularity and primarily affects male bodybuilders - should be re-classified as an eating disorder. Muscle dysmorphia was originally conceptualized as the opposite form of anorexia nervosa and termed "reverse anorexia" due to shared obsessive-compulsive features relating to eating and exercise behaviours. In both cases, obsessive adherence to dietary and exercise regimes motivated by intense body dissatisfaction or dysmorphia causes significant psychological distress and impairment in important areas of life such as occupational and social functioning.

The clear differences between muscle dysmorphia and anorexia nervosa relating to the pursuit of muscularity versus the drive for thinness likely reflect the gender-specific body ideals and distinct sociocultural pressures impacting on males and females. Media representations of hyper-muscular, lean male physiques, magazines featuring diet plans and workout programmes placing pressure on men to 'get shredded', sports supplements adverts targeting men, and appearance-potent social media content work together to construct an image of the ideal male body and provide directives about how to achieve it. Moreover, as Scott Griffiths, a research fellow investigating eating disorders, muscle dysmorphia and anabolic steroid use at the University of Melbourne, points out in his TEDx talk on muscle dysmorphia, "eating disorders are moving targets. They change in response to the types of bodies our society values among its constituents". Situating eating disorder symptoms within a sociocultural context allows us to move beyond blaming individuals for their dietary and exercise decision, and to recognize the modern cultural influences contributing to the rise in concerns about leanness and muscularity experienced by men, and increasingly, women also.

Investigating the rise of eating disorders in men calls for a nuanced exploration of how gender impacts people's lived, embodied experiences. Understanding how different forms of body-based oppression, such as sexism, racism, weight stigma, appearance discrimination and ableism, intersect with one another, and the role that social, cultural, political and technological forces play in propagating these beliefs, is required if we are to bring about systems-level change necessary for people to live at peace in their bodies. Addressing the gender bias that surrounds eating disorders involves developing diagnostic tools that are sensitive to the issues affecting men and gender-diverse folk, and training treatment providers in delivering gender-literate, culturally competent care. More fundamentally, extending our understanding of eating disorders to people of all genders is an important step toward de-stigmatizing eating disorders and achieving parity not only with physical illnesses, but also other mental health conditions with more equal gender distribution. Eating disorders are complex, multi-faceted conditions involving biological, psychological and sociocultural factors: gender provides us with an analytic lens through which these different components can be understood.