When I meet new people and tell them that I am a clinical psychologist, I usually hear one of two questions. Question one -- "Are you analyzing me?" -- can be answered rather succinctly ("I wasn't, until you just said that").
Question two -- "Do you have a specialty?" -- is a trickier ask to answer. I might respond that I specialize in the practice of evidence-based psychotherapies like cognitive behavioral therapy and interpersonal therapy, and the development and testing of novel psychotherapies. But then I must explain what that means. I might respond that I treat adults with anxiety, mood and eating disorders. This usually leads to many more questions too. Instead, in an effort to keep it brief and move the conversation along, I might say simply, "Eating disorders." I do, after all, spend part of my time at a specialized eating disorders program. If this is my response, then I am likely to hear Question 3: "So you only treat women?"
No. In my years of working at the New York State Psychiatric Institute/Columbia Center for Eating Disorders and in private practice, I have certainly treated male patients. Men with binge eating disorder. Men with bulimia nervosa. And yes, men with anorexia nervosa.
In a country and culture that has historically defined eating disorders and preoccupation with appearance as a "women's issue," men suffering from body image and eating problems have a stigma to overcome. It is true that more women are affected by eating disorders than men, as is also the case for many anxiety and mood disorders. However, recent U.S. survey data of lifetime eating disorder prevalence suggest that binge eating disorder is about as common in men as women, and that for both bulimia and anorexia nervosa, men represent approximately one-fourth of the cases. Prior studies put forth a more modest, albeit still quite concerning, estimate with roughly one-tenth of cases of bulimia and anorexia nervosa being male.
Anorexia nervosa is a dangerous illness (with a mortality rate as high as that seen in any psychiatric illness) that remains a relative enigma to treat. It also suffers from a two-pronged PR problem: a glorification of a thin-ideal within our culture and a misconception that it is not an equal opportunity problem. Men may be more likely to be misdiagnosed and less likely to receive specialized treatment, but they certainly can still suffer from anorexia nervosa.
Perhaps acknowledging the issue of potential misdiagnosis, the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (a diagnostic dictionary for mental health providers) made an important change to the diagnostic criteria for anorexia nervosa. The amenorrhea criterion, which stipulated the absence of a menstrual period for 3 months to receive a diagnosis, was removed. This feature, frequently but not always present in women, might have primed clinicians not to consider boys and men for the diagnosis; its removal may help more males with anorexia nervosa to be properly identified.
But to me, the most important thing to understand about this condition in men is that it looks nearly identical to its presentation in women. These are males who are underweight for their height (or, in the case of still-growing boys, for their age and expected growth curve). They are afraid -- of eating fat, of gaining weight, of becoming fat. This fear is sometimes well articulated, and other times must be observed by friends and family as their loved one struggles to eat the foods or change the behaviors that would help him or her to attain healthy weight. They are obsessed -- with food calories, with exercise, with appearance (be it body shape or weight on the scale). And though their appearance is the primary way in which they evaluate themselves, they do not seem to measure up at any size.
Are there differences between men and women with anorexia nervosa? Sure, research in this area does suggest a few. The motivation for men and boys to control or influence appearance may, in some cases, be different. For instance, whereas our culture seems to emphasize form over function for women's bodies, function -- speed, strength, ability to fight -- remains awfully important for men. Male body dissatisfaction may be rooted in actual or perceived difficulty with physical performance rather than appearance. (Though, the same may be said of female athletes.) However, once anorexia nervosa has firmly taken hold of an individual, the experience of perpetual, extreme body dissatisfaction or distortion manifests similarly despite potentially different origins.
Women and men with eating disorders sometimes abuse substances like laxatives, diuretics, or diet pills in a misguided effort to lose or control weight (these substances mostly dehydrate the body or slow motility while building tolerance over time), but men are more likely to have tried a class of illegal substances called APEDs, appearance and performance enhancing drugs. APED use is associated with increased risk for eating disorders and body image problems. The common thread here is the persistent use of harmful substances, hazardous in type, quantity or both, in the name of "health."
If we can accept that (1) men can have anorexia nervosa and (2) there is more similarity across the sexes than difference (acknowledging, of course, enough heterogeneity for each individual to have his or her own narrative of the illness and experience in recovery), then identification and treatment of men with this condition can improve.
Men with anorexia nervosa, suffer from the same physiological effects of malnutrition as women (in fact, the seminal study about these effects was done in men) and must, first and foremost, normalize their weight and physical health to have a chance at truly restoring psychological health. Improvements in body image and body satisfaction are likely to lag behind the rest, as is the case for many women. Behavioral treatments, sometimes within the structure of programs that provide supervision during and after meals, may be required. A multi-disciplinary treatment team, including a dietitian, psychotherapist, and medical doctor such as a psychiatrist or primary care physician, may be beneficial for outpatient care. Involvement of loved ones - a family of origin or of the patient's choosing -- is likely to help men with anorexia nervosa to get and stay well, just as it does for their female counterparts. And early identification of the illness may confer the best chance of quick, sustained recovery.
Yes, there are men (and boys) with anorexia nervosa. I've seen them and worked with them through the complex, arduous stages of recovery. I know that there are many more out there in need of treatment. They need us to be aware, to be compassionate, and to help.
For information on eating disorder treatment and research, contact the Center for Eating Disorders at 646-774-8066 (New York State Psychiatric Institute/Columbia University Medical Center) or 888-694-5700 (New York-Presbyterian Hospital/ Westchester Division), or the National Eating Disorders Association at 1-800-273-8255.
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Dr. Glasofer is a clinical psychologist and assistant professor of clinical psychology in psychiatry at Columbia University College of Physicians and Surgeons. The opinions expressed here are entirely her own.