By Sarah K. Ravin, Ph.D.
“If you were a girl, I’d say you were anorexic.” These words were spoken to 17-year-old Andy by the pediatrician who had seen him since birth. Following a New Year’s Resolution to “get a 6-pack,” Andy abruptly stopped eating snacks and sweets and subsisted primarily on massive quantities of grilled chicken breasts, vegetables, and protein shakes while lifting weights and running for two hours per day. By the time he presented in my office in mid-March, he had lost a significant amount of weight, his hair was falling out, and he barely had the energy to hold his head upright. Andy’s pediatrician suggested that he might be depressed and encouraged him to “get out more.” Fortunately, Andy’s concerned mother, who suspected that her son was suffering from more than depression, brought him to the adolescent eating disorders clinic where I was working at the time. I diagnosed Andy with Anorexia Nervosa. As it turned out, his depressed mood was secondary to semi-starvation, and he returned to his jovial, energetic self within a few months of beginning treatment for the eating disorder.
Andy was my patient while I was a graduate student therapist-in-training at Children’s National Medical Center’s Eating Disorders Clinic. He was the first boy with an eating disorder that I treated, but certainly not the last. Since then, I’ve seen dozens of boys and young men with Bulimia Nervosa, Avoidant-Restrictive Food Intake Disorder (ARFID), Binge Eating Disorder, and Anorexia Nervosa. Fortunately, things have changed for the better in the 15 years since I had the privilege of working with Andy. Healthcare providers, and society as a whole, have become more aware that eating disorders affect both males and females. Nonetheless, boys face some unique barriers to treatment and recovery.
The stereotype of eating disorders being a “girl problem” causes males with eating disorders to face even more stigma than their female counterparts. And because they typically associate eating disorders with girls and young women, healthcare providers may be less likely to ask eating disorder screening questions to males and less likely to make a proper diagnosis. The delay in diagnosis causes the illness to become more entrenched over time. By the time a boy does present for specialist eating disorder treatment, months or even years after symptoms began, he may be much more severely ill.
The core symptoms of eating disorders are usually the same in males as in females: a pervasive pattern of food restriction, binge eating, and/or purging that becomes self-perpetuating and adversely impacts physical and psychological health; severe anxiety around food and weight; and, often, body image disturbance. In my experience, male eating disorders and female eating disorders are more alike than different. That being said, there are some key differences in symptom presentation between genders.
Males with restrictive eating disorders are often preoccupied with achieving and maintaining a very lean, muscular physique. They may strive to be ripped, shredded, chiseled, and have “6-pack abs.” To this end, boys with eating disorders often eat massive quantities of protein and take supplements or even steroids to enhance their muscularity.
Boys who suffer from bulimia or binge eating disorder may find it fairly easy hide their symptoms from themselves and from others, as it is common for healthy growing teen boys to devour a large pizza or multiple sandwiches in a row. Parents, siblings, and peers may find it amusing or impressive to watch teen boys eat massive quantities of food in an out-of-control manner, unaware of the extreme distress that the boy feels during and after binge eating.
Semi-starvation affects every system of the male body and is especially dangerous in children, adolescents and young adults who are still growing and developing. Boys with restrictive eating disorders often experience bradycardia, hypotension, and hypothermia as well as low testosterone, low vitamin D, and osteopenia. Many boys with eating disorders consume excessive amounts of protein in attempt to build muscle. Diets too high in protein can result in digestive problems and damage to the liver and kidneys. Anabolic steroids, which are commonly abused in boys with eating disorders, can cause cardiovascular disease, extreme aggression, mania, liver damage, growth stunting, and testicular cancer. Boys with purging symptoms are at risk of electrolyte imbalances.
The prevalence of eating disorders in males is higher than we once thought. I recall, early in my training, learning that approximately 10% of those with eating disorders were female. Today, however, the National Eating Disorders Association estimates that nearly 1/3 of individuals with eating disorders are male. It is unclear whether this change over time is due to an actual increased incidence of these illnesses in males, or simply due to increased awareness, making males more likely to be diagnosed today than in years past. Unfortunately, to this day, males are much less likely than females to seek eating disorder treatment, so it is likely that there are millions of undiagnosed, untreated boys and men.
Studies show that gay and bisexual males are at higher risk of developing eating disorders than heterosexual males. There are several possible reasons for this. First, many LGBTQIA+ individuals experience high levels of discrimination and oppression, which adversely impacts mental and physical health. Second, gay and bisexual males experience heightened pressures to achieve a particular body ideal, which may be slimmer and leaner than the heterosexual ideal. Third, eating disorders and sexual orientation have a shared risk factor of increased estrogen exposure in utero. Research suggests that individuals exposed to higher levels of estrogen in the womb are more likely to develop eating disorders in adolescence and are more likely to identify as gay. Transgender and gender non-binary individuals are also at much higher risk of eating disorders than cisgender and gender-conforming folks for all of the reasons cited above, plus the extreme dysphoria that results from living in a body that does not conform to one’s identity.
On the bright side, I have found that boys with eating disorders often have an easier time stepping back into their lives after recovery than girls do. This may be due to the reality that our society’s body ideals are less harsh towards males than towards females across the life span. Teen boys and college-aged young men may be less likely to diet or obsess about their weight than girls, so spending time with friends and eating with peers in the cafeteria poses less of a trigger hazard.
In closing, I’d like to share an inspiring quote from a former patient of mine – a teenaged boy whom I treated for an eating disorder several years ago. After recovering fully, he told me in his final session: “I used to see my body as the enemy; something I had to beat into submission. But now, my body is my companion. We work together and help each other. We’re on the same team.”