Men with Eating Disorders
Eating disorders such as Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Eating disorders Not Otherwise Specified (EDNOS) have commonly been labeled as a “woman’s disease” mostly because the majority of individuals in private clinic treatment and in treatment centers are female. However, men do suffer from eating disorders and may suffer more often in silence as the label of “woman’s disease” could easily embarrass a man out of seeking necessary help. Cases of men seeking treatment for eating disorders, although particularly sparse, are documented as 1 in every 10 individuals who seek treatment (Scott, 1986). Their age of onset, diagnostic criteria, and specific psychopathology is very similar to women but their treatment may actually be more difficult as treatment methods are more tailored towards women (Ralph F. Wilps, Jr. Male Bulimia Nervosa: An Autobiographical Case Study). This essay will cover the history of the male eating disorder, theories for their etiology including similarities and differences in relation to women, and treatments methods.
Male eating disorder cases are few and far between but they do exist. Three of the earliest documented cases were recorded between the years of 1689 and 1790 (Joseph A. Silverman. Anorexia Nervosa in the Male: Early Historic Cases). Because of strict guidelines required to diagnose eating disorders through the Diagnostic and Statistics Manual (DSM), these cases were controversial for some time, but medical descriptions in each case eventually lead many professionals to believe that these patients were suffering and being treated for eating disorders far before the disease had a name. The first reported case of an eating disorder in a male was only the second case to ever be recorded in history. It is as follows,
The son of the Reverend Minister Steele, my very good friend, about the sixteenth Year of his age, fell gradually into a total want of Appetite, occasioned by his studying too hard, and the Passions of his Mind, and upon that into an Universal Atrophy, pining away more and more for the space of two years, without any Cough, Fever, or any other symptom of any Distemper of his lungs, or any other Entrail; as also without a Looseness, or Diabetes, or any other sign of a Colliquation, or Preternatural Evacuation. And therefore I judg’d this Consumption to be Nervous, and to have its seat in the whole habit of the Body, and to arise from the System of nerves being distemper’d. I began, and first attempted his Cure with the use of Antiscorbutick, Bitter, and Chalybeate Medicines, as well Natural as Artificial, but without any benefit; and therefore when I found that the former method did not answer our Expectations, I advis’d him to abandon his Studies, to go into the Country Air, and to use riding and a Milk Diet (and especially to drink Asses Milk) for a long time. By the use of which he recover’d his Health in great measure, though he is not yet perfectly freed from a consumptive state; and what will be the event of this Method, does not yet plainly appear (Morton, 1689, 1694).
Years after the above report, Robert Whytt presented a case study of a second mysterious illness affecting a young man in a much similar way. His study is as follows,
ANOTHER lad of 14 years of age, of a thin and delicate habit, and of quick and lively feelings, whose pulse in health used to beat beyond 70 and 80 times a minute; about the beginning of June 1757, was observed to be low-spirited and thoughtful, to lose his appetite and have bad digestion. Altho’ he lost flesh daily, yet he had no nightsweats, to extraordinary discharge of urine and was costive. His tongue was clean, his skin cooler than natural, and when in bed, his pulse beat only 43 times a minute; nay about the middle of July, when reduced almost to skin and bone, his pulse in a horizontal posture, did not exceed 39. About the end of August, his distemper took a sudden turn; he then began to have such a craving for food, with a quick digestion, that he grew faint unless he ate almost every two hours; he had two or three stools-a-day; his pulse beat from 96 to 110; hi skin was warm, and his veins, which scarce could be seen before, became now turgid with blood. The strong apprehensions he formerly had of dying left him, he was sure he should recover; and accordingly, by the middle of October, he was plumper than ever he had been before. Towards the end of November, his appetite became moderate, and his pulse gradually returned to its natural state.
... (Robert Whytt, 1714-1766, Eighteenth century limner of anorexia nervosa and bulimia. Int. J. Eating Disorders, 7, 439-441).
The third case, in 1786, describes an incredible case of fasting which lasted 78 days and sadly ended in the young mans death. Robert Willan published comments about his 15 bedside visits to the young man through out the duration of his fast.
The propositus, “a young man of a studious and melancholic turn of mind”, had developed symptoms of indigestion during the years 1784-5. On Jan.21 1786, he embarked on a severe course of abstinence allegedly in the hope of relieving his disagreeable complaints. [Willan, suggests that the fasting was a result of “some mistaken notions in religion.”].
The patient “…suddenly withdrew from business, and the society of his friends, took lodgings in an obscure street, and entered upon his plan; which was, to abstain from all solid food, and only to moisten his mouth, from time to time, with water slightly flavoured with juice of oranges.”
“After three days of abstinence, the craving, or desire for food, which was at first very troublesome, left him entirely.”
…From the 50th to the 60th day, his strength failed rapidly, causing him great alarm. He had hitherto believed that “his support was preternatural.” By day 60…delusion had vanished; he found himself gradually wasting and sinking to the grave.”
On March 23,1786… “He was at that time emaciated to a most astonishing degree, the muscles of the face being entirely shrunk; his cheek-bones and processus zygomatici stood prominent and distinct, affording a most ghastly appearance: his abdomen was concave, the umbilicus seeming to be retracted, from the collapse of his intestines; the skin and abdominal muscles were shrunk below the brim of his pelvis,…His limbs were reduced to the greatest degree of tenuity… His whole appearance suggested the idea of a skeleton, prepared by drying the muscles upon it…His eyes were not deficient in luster, and his voice remained clear and sound, notwithstanding his general weakness
By March 25th, day 63 the man had food cravings. The next day he ate a large quantity of bread and butter and vomited.
By March 29th, day 67 he developed memory lapses and became frantic and unmanageable…for the next three days he ate little, and became sullen and withdrawn.
From April 6-8 the patient took whatever nourishment was offered. The next day, in the morning, the young man died.
These descriptive reports are only the known documented incidences of eating disorders in men. More cases could have easily existed as some continue to do today without medical intervention. It would be very interesting to know what the life situations these young men were experiencing at the time of their disorder so as to compare and contrast with the information known now regarding current affected individuals and predisposition factors.
Predisposing factors for eating disorders in males are of staggering complexity as they also are with women. Firstly and most importantly an individual usually possess personality predispositions (primary) for eating disorders. These include low self-esteem, dependant personality styles, avoidant behaviours, passive-aggressive tendencies, quietness/shyness, sensitivity, heightened intelligence and intuitive qualities and high perception to emotions in oneself and in others. As well as one possessing some or all of the above primary predispositions, it is usually the case that they went through a negative experience regarding their personality or body at their most vulnerable time as a child. With these primary personality and experience factors present the disorder appears to manifest and maintain itself through the media, culture, and continued negative self-concepts (secondary).
Similarities between men and woman include feelings of shame in relation to the physical appearance of the body. In a case study written by Ralph F. Wilps Jr., he re-counts his own personal journey with bulimia and identifies his feelings of shame as a young boy being bullied by his peers because of his small frame. Born a sensitive and quiet child interested in books and writing, he already had a primary predisposition for the disorder. He also took an emotional beating by his father who was, in contrast to Wilps, considered a strong, powerful man. As a young child Wilps father was forced to take care of his entire family, worked in the mines at age 9 and then struggled on to have a successful career as a top athlete. As a result of his upbringing, Wilps’s father continued to provide for others but thoroughly resented all that were weaker than him. His father forced Wilps to work in a physically laborious job where he also endured teasing by his colleagues. In Wilps case as well as for many others of both sexes, pressure with direct emphases on the body was a definite contributing factor to the onset of his eating disorder.
In cases related to male eating disorders, there have been conflicting reports of whether or not sexuality is linked to the etiology of the disease. Low testosterone in males due to injury as children has been a topic in clinical studies of men with eating disorders (Wilps Jr.). There is limited literature, however, stating that altered endocrine function is a contributing factor. As well, there have been studies of more and more homosexual and bisexual men with eating disorders. In 1984, Herzog et al reported a 26% incidence of homosexuality among anorectic and bulimic males, compared with 4% among female anorectic and bulimic patients cared for in the same clinic. Conversely, in another study in 1986, Pope et al found homosexual activity in only 1 of 14 patients (Angela D. Mickalide, Sociocultural Factors Influencing Weight Among Males). Gender confusion and the precipitation of an eating disorder has been a conflicting idea for many years. Because eating disorders are considered a “woman’s disease” this hypothesis appeared to hold truth if a man were to admit he was a sufferer. A large chunk, approximately 50% (Crisp; Dally; Crisp and Toms; cf Scott) of individuals do report that their disorders began to take shape when they realized they were homosexual. Burns and Crisp, 1984, report that their anorexic patients avoided sexual activity because of ego-dystonic homosexuality, and two bulimic patients in their clinic reported that their eating disorders developed around the same time they began to think of themselves as homosexual. The fact that eating disorders exist in homosexual males does not indicate that homosexuality predisposes one to an eating disorder, but that the stress and inner conflict that comes with being different can certainly propel the disease.
Anorectic males have considerable discomfort surrounding sexuality and intimacy. A study conducted by Fichter and Daser (1987) compared 29 male anorexics to 23 female anorexics. Males showed abundantly more sexual anxieties than females and even expressed a severe sense of disgust towards sexual relations. The process of starvation provided these patients with a sense of relief as their sexual drive ceased consequently giving them a reason to continue their distorted eating behaviour.
Another older but interesting theory in regards to sexuality, is based on the hypothesis of male anorectic behaviour as an attempt to remain childlike, remain dependant on the mother figure and avoid developing a masculine role in the world. In relation to this theory, the starving process is seen as an attempt to eliminate the mother from the body, as in this case the removal of fat is associated with the removal of the feminine form. (Falstein et al., 1956).
The anorectic tendencies that are predominate in affected males may take on societal female qualities such as, lack of assertiveness, or an over all lack of confidence but this is present in all individuals affected with the disease and also crosses boarders into other mental disorders such as depression and anxiety disorders. The fact that a man must maintain a dominant, masculine posture throughout his life is simply a cultural stereotype and is more created by the media then by real life men. Men can be biologically quiet and submissive at birth just as woman can be dominant and confident.
Culture and media concerns play a definite secondary role in eating disorder formation and maintainence. In a study conducted by Ann Kearney-Cooke and Paul Steichen-Asch, out of three groups of men, two groups (the non-eating disordered group and the at risk eating disordered group) preferred the classic body shape that represents the letter V. The V shape indicates a strong, durable upper body, able to easily perform physically laborious tasks. This body had its place in an era when the majority of work was quite labour intensive. This means that this continued idealization of body shape may be one of the oldest cultural misconceptions of our time as the need for it no longer exists. Instead, the media continues to seek it not for it’s usefulness, but for it’s beauty and strength, consequently labeling it as the only real shape of raw masculine power. For young developing men, the media influence surely triggers this stereotypical want, as well as and more directly, ones peers whom are also influenced by the media to the same degree.
Not only is a young man going through somatic changes and pressure to have the perfect body, but also he is searching for personal identity. The ideal male personality is still portrayed as one having superiority over others, independent, tough, confident, courageous, and aggressive. This type of pressure can lead some men to react by taking part in distorted eating practices as well as isolating emotionally and therefore limiting individual potential. The definition of manhood is distorted and unrealistic just as is the definition of womanhood. Although the stereotypes put pressure on young men and women to conform different aspects of their bodies and personalities, they are similar in the fact that they do put pressure on one to conform. The results of this pressure ultimately leads to disordered eating and if lucky, treatment.
Medical treatment of eating disorders is a step by step process. It begins by psychological assessments where several aspects of personality, intelligence and behaviour are assessed. The patient then undergoes treatment in order to become medically stable. If one is so emanciated that cognitive functioning is inhibited, one can not be expected to fully excel in a theraputic setting. In an eating disorder clinic, the main goal is to increase patient weight and nourish the body. Patients are nutritionally educated throughout their entire treatment, however, it is very standard. Once patients reach a desired and stable weight as determined by their medical practitioners, they are now able to undergo psychotherapy. Effective psychotherapy treatment has three principle characteristics: 1) it focuses on resolution of a central dynamic formulation; 2) is it multimodal in form; 3) it is sequential in its techniques according to the needs of the patient, not the training of the therapist (Arnold E. Anderson. Diagnosis and Treatment of Males with Eating Disorders, 148-149.).
The central dynamic function of an individual is determined by the therapist to be the main reason for why the eating disorder developed. Understanding the purpose of the eating disorder in the patients life helps to shape the direction in which the therapy will take, thereby planting roots for the recovery process.
Multimodal formatting is the introduction of different types of therapy techniques, generally integrating group, family and individual therapy. Group therapy allows clients to be supported and encouraged by their peers in a way that may be more accepted by the client than support from the therapist.
Finally, meeting the needs of the patient begins with a “sequence of methods” that is tailored to fit the patient. The sequence begins with supportive psychotherapy. The purpose is simply to educate the patient and encourage him to recover.
Supportive therapy allows the patient to understand his disease and also understand the methods used his treatment up until this point.
Secondly, cognitive-behavioural therapy is used in the treatment of both AN and BN but has been found to be more successful in the recovery of BN patients. The purpose of cognitive therapy is to identify the underlying distorted thought processes of the patient and then to change them.
Thirdly, psychodynamic psychotherapy helps the patient connect the dots between his eating disorder and traumatic or crucial life events that may have helped create the disorder.
Concluding the sequence is existential psychotherapy. This therapy encourages the patient to see the meaning of life beyond the suffering in hopes that the patient will strive to move forward.
Moving through the “sequence of methods” has been tested on numerous patients and has been one of the most effective forms of medical treatment for eating disorders. This being said, the movement through the stages could take years and setbacks could occur at any stage. Patients with difficult personalities, eg. Confrontational, has also been known to inhibit growth through the stages. Therapy at any stage and with any personality, should be a supportive environment where the patient can move at his own pace. As stated above, pressure is one of the predisposing factors that contributes to the development of eating disorders and should not be present in the recovery process.
It has been suggested that men may have a worse recovery outcome than women. Studies have shown, however, that there are such similarities between the genders that there should be no reason to say why males would not succeed to live as full lives as recovered women. In a follow up by Anderson and Mikalide, 1983, the average male with an eating disorder was still in a thin-normal weight range and living a reasonably normal life. The eating disorder process for men and women moves along similar paths and this includes recovery. The only differences being the specific cultural, stereotypical and peer pressures which focus on different aspects of the male body and personality.
In conclusion, men with eating disorders do exist. The second recorded document of an eating disorder was in a male and there may have been many more sufferers that went undocumented due to lack of financial resources; the same holds true for today. The modern man may also feel shame in admitting he battles with eating normally because the majority of individuals diagnosed with AN, BN, and EDNOS and the majority who seek treatment are women. It is already challenging to admit one has an eating disorder, but for a man to admit he has the illness is that much more difficult as there is a stigma attached to it. This is especially true if the man is homosexual. He may not be ready to be labeled as gay, or may not be particularly feminine as the stereotype suggests (of gay men as well as eating disorders). The stereotype of being “more feminine” to have an eating disorder has proven true in some cases (admitting to himself he is homosexual at time of onset of the disorder), but not for others (biological predispositions that were not nurtured as a child) so in light of these facts, it is easy to say that AN, BN, and EDNOS is not strictly a woman’s disease. It is media, culture, personality predispositions and continued support of a negative self-image that forms and maintains the illness in both men and woman alike. There should be continued support and encouragement for affected males to step forward and challenge themselves with recovery. A woman afflicted with the disorder may feel alone while living in secret with her disorder, but she knows that she will not be judged if she makes the choice to recover. Imagine how alone a man in the same situation may feel.