Restrictive eating behaviors in boys and men.

Is the eating disorder spectrum really much more prevalent in women than men?

I expect the answer is “No.”



Mental Functions Socially-Derived and Sex-Delineated

The more time I spend buried in the Diagnostic and Statistical Manual of Mental Illness (DSM), the more I see a pervasive sexism in the checklists of symptoms required for diagnosis of almost all purported mental illnesses.

Women supposedly suffer anxiety disorders far more than men. But look at the symptom list for, let’s say generalized anxiety disorder: 

  1. At least 6 months of "excessive anxiety and worry" about a variety of events and situations. Generally, "excessive" can be interpreted as more than would be expected for a particular situation or event. Most people become anxious over certain things, but the intensity of the anxiety typically corresponds to the situation.
  2. There is significant difficulty in controlling the anxiety and worry. If someone has a very difficult struggle to regain control, relax, or cope with the anxiety and worry, then this requirement is met.
  3. The presence for most days over the previous six months of 3 or more (only 1 for children) of the following symptoms:
  4. 1. Feeling wound-up, tense, or restless
  5. 2. Easily becoming fatigued or worn-out
  6. 3. Concentration problems
  7. 4. Irritability
  8. 5. Significant tension in muscles
  9. 6. Difficulty with sleep
  10. The symptoms are not part of another mental disorder.
  11. The symptoms cause "clinically significant distress" or problems functioning in daily life. "Clinically significant" is the part that relies on the perspective of the treatment provider. Some people can have many of the aforementioned symptoms and cope with them well enough to maintain a high level of functioning.
  12. The condition is not due to a substance or medical issue.

Now what if, magically, the symptom list for generalized anxiety disorder in the DSM-IV read more like this:

The presence for most days of the previous six months of five or more of the following symptoms:

  1. Heightened irritability and impatience
  2. Catastrophisation: anticipating the worst, perseverating on "worst case" scenarios
  3. Feeling restless and agitated
  4. Tension, aches, pains and/or gastrointestinal complaints
  5. Insomnia or disrupted sleep cycles
  6. Rumination (particularly on past or recent interactions in which the patient felt questioned, disrespected or overlooked)
  7. Avoidance (lower than usual levels of social interaction, involvement in familial activities…)
  8. More frequent and more intense expressions of anger
  9. Indecisiveness
  10. The symptoms are not part of another mental disorder

With the above list, many more men will find themselves suffering from generalized anxiety disorder than would currently be the case using the actual DSM-IV criteria.

And inherently this is the problem with solely using symptom lists as a way to diagnose patients.

Symptoms of all mental functions (normal or abnormal) are expressed within a social construct. In fact that is why so many people to this day believe that mental disorders are somehow in the patient’s control.

Just because a patient expresses a physiological anomaly in the brain in a socially identifiable or recognizable way, does not mean that the expression is somehow in the patient’s control.

The psychosis associated with schizophrenia and bi-polar disorder has tracked to social concerns throughout the 20th century. While the level and intensity of delusions were unchanged, by comparison in the early 1900s patients believed that they had been infected by syphilis, by the 1950s they were more apt to believe they were being spied upon (the Cold War) and recently delusions relate to computers, the internet and computer games.

Because the brain is a social organ, that it is able to lock onto socially-relevant concepts in the expression of delusions in the case of psychoses, obviously, does not render the delusions themselves within the realm of conscious direction or control.

The same is true of the expression of the eating disorder spectrum.

Recent Shifts In Symptom Expression of the Eating Disorder Spectrum for Both Men and Women

So, now with all that in mind let’s turn our attention to the eating disorder spectrum in boys and men.

Eating disorders in men are supposedly on the rise, but what this means is that boys and men have begun to apply self-administered starvation (anorexia nervosa) in greater numbers. However, they have been pervasively expressing other facets of the same spectrum disorder likely in the same numbers as women have been expressing the facets of starvation and starvation/reactive eating cycles, all along.

Primarily, boys and men disproportionately express the facets of restriction through excessive exercise and strict adherence to so-called “healthy” diets. They look to develop muscle mass alongside extremely low body fat, to allow for the muscles to be clearly visible.

For the more recent shift to starvation in men, the media has coined the term “Manorexia”. However it is the same underlying genetic predispositions for the eating disorder spectrum that are triggered in both men and women.

The traditionally dominant facets of the eating disorder spectrum that were once purely seen in men or women are now seen in both sexes. Women on the eating disorder spectrum will use excessive exercise and men will use extreme restriction of calories in ever increasing numbers.

These shifts are attributable to an increased acceptance of muscle-definition in women and a recent shift away from top-heavy, muscle bound males to boyish, thin shapes in the media.

Just as a symptoms list can inadvertently favor socially-derived behaviors found only in one sex, so too can the design of research studies inadvertently presume outcomes that are sex determined.

Until the 1990s, most research studies could dependably identify the impact that idealized body images in the media had on young girls and women. But when those same tests were applied to boys and men it appeared as though they were unaffected by idealized male body images in the media.

However, once the tests were re-designed to avoid bias for wanting to be thinner, it was discovered that boys and men are just as likely to see a discrepancy between their own bodies and that of what is considered ideal and to be dissatisfied with that discrepancy – but the determining factor was musculature and not necessarily thinness.

Generally, going on a diet (restricting calories) is seen by pre-adolescent boys as something girls do. In interviews, all boys seem able to describe the diet their mothers are currently on and that they would not consider dieting to lose weight, but rather would exercise instead.

However, at adolescence more boys will consider both restricting calories and exercising more if they believed they were too fat.

Marketing, Media, Dissatisfaction and Sexual Competition

The process of objectifying male bodies in the media accelerated greatly in the 1980s. Because the objectification of male bodies was considered the exclusive realm of the male homosexual community at the time, it was common for male models to clearly state their heterosexuality. Objectifying the male body for heterosexual competition is not new in our cultures, but it was challenging for the puritanical roots of America to adjust, but adjust it did.

Quickly, male models, celebrities and film stars all shed body fat, body hair and bulked up the upper torso to reinforce this ideal.

In one of the articles I read in preparing this post the author asked a really useful question: Taking away all the media images, how many naked (or almost naked) bodies have you seen or are likely to see in your lifetime?

Sexual competition has theoretically increased exponentially, but in reality it has not. I may live in a city of two million people, but propinquity determines my potential mate(s) as much as it ever has throughout history.

And yet a young teenage boy is familiar with Mylie Cyrus’s thighs, or Selena Gomez’s hips despite the fact that he will never know them. How can that fact not impact the expectations we all have for competing against our own sex for the attention of the other (or competing with the same sex or both sexes)?

And while we can all usually distinguish between virtual and real existence, it is clear that our brains don’t necessarily have that totally figured out.

The foundation of marketing is creating dissatisfaction. Not too many satisfied people have to scour the malls for shopping therapy.

We are bombarded with thousands of messages each day letting us know that we should a) be dissatisfied and b) the product/service in question will ensure we once again measure up.

It is the water in which we all swim. So much so, that asking any of us if we are affected or impacted by all this messaging is exactly like asking a fish whether they find their surrounding water impacts the way they think and feel.

Just as with women, men don’t catch eating disorders from our image-obsessed and reinforcing culture. However, environmental triggers all place pressure on the eating disorder/anxiety disorder genotype(s). Dissatisfaction is what pushes a girl of 8 to begin dieting and a boy of 11 to begin weight lifting and working out.

Specific Challenges for Boys and Men on the Eating Disorder Spectrum

The biggest challenge facing boys and men on the eating disorder spectrum is that no one expects it to happen.

Our societal panic over obesity usually buffers parents from being able to identify that an effort to “be healthy” in their boy is actually cause for concern. Parents are just as likely to encourage their daughter as she decides to cut out sugars or desserts, failing to recognize that having a young developing person think in those ways is already a huge danger sign.

But if we think back to the pre-adolescent boys who were clear that dieting is a girl’s thing, then we start to understand why treating the eating disorder spectrum in male patients is not exactly the same as treating it in women.

There is more embarrassment for the patient and his family because it is considered a female mental disorder. Countless gender studies show that both men and women are more comfortable with their daughters expressing behaviors that are traditionally viewed as masculine than for their sons to show any feminine tendencies.

Depending on the family of origin, the parents and/or the patient may be unwilling to seek intervention because an expectation of “being a man and just getting over it” prevails. We have to be careful to avoid over emphasizing this macho concept as both men and women in our culture see the need to seek help as a sign of personal weakness.

As with their female counterparts, the male REDS patients experience tremendous shame, self-loathing and a sense that they should be able to overcome their eating disorder on their own.

The intolerance for gender fluidity from male to female, as I mentioned above, is further worsened by the fact that even receiving a clinical diagnosis for a boy is difficult given that the DSM-IV (and soon to be DSM-5) still persists in normative female socially-derived expressions of the eating disorders.

Boys and men are far more likely to be thrown into the ED-NOS (eating disorder not otherwise specified) category because they cannot meet the criteria of anorexia nervosa or bulimia nervosa and their various sub-types.

The problem with an ED-NOS diagnosis, is that there can be more emphasis on the co-morbid conditions of compulsions, anxiety and/or depression rather than adequate energy intake to alleviate the huge energy deficut largely responsible for the rise of compulsions, anxieties and depression in any patient (male or female).

And of course having amenorrhea (loss of regular menstrual cycle) identified as a criterion for anorexia nervosa either automatically includes all men (no man experiences a regular menstrual cycle), or conversely excludes all men (no man can attain a regular menstrual cycle and therefore cannot lose one) from that diagnosis altogether.

In other words, boys and men actively on the eating disorder spectrum are far more likely to be wrongly prescribed anti-depressants and anti-psychotics and are unable to have their eating disorder successfully resolved even in circumstances where they have been identified as needing intervention.

If a boy develops a severe clinical case of an eating disorder, then hospitalization often involves more feelings of isolation and awkwardness. While he will receive the necessary medical stabilization and re-feeding, he will not find group therapy sessions as productive as his female counterparts (keeping in mind anyone can find group therapy unproductive). One-on-one psychoeducational therapy is critical both in the inpatient and subsequent outpatient settings.

The decision to seek help is as difficult for a male as it is for a female on this spectrum, but the male may additionally feel reluctant due to some general misconceptions surrounding the sexual orientation of men who suffer from this disorder.

Studies in the 1980s suggested that anorexia was far more prevalent in the male homosexual community than in the heterosexual community. However, as I have mentioned, the objectification of males for heterosexual competition in the media since that time has completely erased the comparative susceptibility of the homosexual community compared to its heterosexual counterpart (if indeed such a disparity even existed in the 1980s*)

* Given that the eating disorder spectrum includes anorexia athletica and orthorexia nervosa, the male heterosexual community suffering from the disorder has not likely increased, but rather has shifted emphasis in the socially-derived expression of the disorder in the past 30 years.

As is the case for women as well, finding adequate care and support for recovery from the eating disorder spectrum is challenging. Many specialists in the field apply outdated concepts for recovery and it is extremely likely that a patient will be advised to stop the recovery process too soon, leaving them extremely vulnerable to relapse.

More Specific Recovery Challenges for Boys and Men

Men in recovery have these particular areas of concern:

  1. Eating enough to provide energy for repair and recovery. The bare minimum for adult males (age 25+) with no history of an eating disorder is 3000 kcal/day. Most young men will easily require 8000-10000 kcal/day through long phases of the recovery process (without the addition of any exertion or activity).
  2. Ceasing all physical activity, and weight lifting. Strangely, some inpatient programs for men in recovery allow for weight training during the recovery process. This practice would be equivalent to allowing female patients to purge throughout the recovery process. Weight training and an intense focus on muscle definition is no more or less a socially-derived expression of the eating disorder spectrum than is purging. Patients must be encouraged to apply non-restrictive behaviors in response to anxieties about body image, muscle definition/weight gain, and food intake.
  3. Working with an accredited therapist to focus on adopting and practicing non-restrictive behaviors.

The physiological aspects of recovery vary little between the sexes. Although women may have the additional marker of the resumption of a menstrual cycle, it is possible to recognize the return to an optimal weight simply when the weight gain tapers off and ceases.

If I were to itemize the points of most resistance for those attempting recovery, the top one would have to be the concept that you simply keep eating the minimum recovery intake guidelines every day and yet you do not just keep gaining and gaining.

There is more than enough clinical evidence to suggest an optimal weight set point exists for all creatures, although the details of how the body works to maintain that optimal point is not fully understood.

The severity of metabolic suppression during starvation cannot be overstated. The body shuts down any biological function it deems not immediately required for survival.

In recovery, the metabolism remains suppressed and the additional energy intake is used for weight regain and physiological repair.

When the body reaches its optimal weight set point, then the metabolism moves back into the normal range. This means that biological functions that were suppressed or completely on hold now resume. And that means that the energy that once went to weight regain and repair, is now used up in day-to-day biological functions.

Many men on the eating disorder spectrum activated the restrictive behaviors by dieting as young boys. Often they were "overweight" at the time. Unfortunately, obesity panic is responsible for encouraging this early dieting behavior.

Boys, even more so than girls, often have a pre-pubertal or early puberty phase where they are "overweight". The body is preparing for physical growth at that time. Had it all been left alone to develop, the “excess” weight would have been absorbed in the massive energy requirements for development into manhood.

Subsequently, boys who develop restrictive behaviors then greatly fear the thought that their optimal weight set point is going unacceptable. It is, however, a fear generated by eating disorder anxieties. Statistically, 70% of all human beings have an optimal weight set point between BMI 22-30. The problem is most want to be where only 4% of the population naturally resides: BMI 18.5-20.9. It's important to work with a therapist to address the misplaced focus on weight and shape defining personal innate value.

The phases of recovery listed in my post here are applicable to both men and women.

The damage associated with both clinical and sub-clinical levels of restriction for men and women is also equivalent. Osteoporosis is heavily under-diagnosed in men, whether dietary restriction is the root cause of the condition or not. As with women, the reversal of osteoporosis that is due to restriction is achievable with complete weight recovery.

Beyond the age of 55, men who have spent their adult lives restricting (that includes excessive exercise) will not be able to reverse the progressive osteoporosis that has occurred, but they will be able to stop further deterioration if they achieve weight recovery at that age (or beyond).

Naturally the sex hormones are impacted equivalently in men and women however the symptoms differ somewhat. Men will experience impotence, reduced sex drive and occasionally reduced presence of facial hair.

The cardiovascular impacts of restriction are similar for both men and women as well. However, the dependence on exercise as a form of restriction in men greatly increases their chance of sudden death.

The higher levels of glucocorticoids (specifically cortisol) in the system may have more serious impacts on the cardiovascular system for men who restrict compared to women, but this has not been clinically confirmed as yet.

Men release less oxytocin in response to higher levels of cortisol and epinephrine (adrenaline) in the body than women do.

Oxytocin allows for us to nurture, feel bonded to loved ones and generally increases relaxation and acceptance. The lower oxytocin response in men may suggest there are not equivalent moderating influences that could protect their bodies from the long term damage of high levels of glucocorticoids in the body.

And just so we’re clear, having an active clinical or subclinical case of an eating disorder is very stressful and generates extremely high levels of glucocorticoids in the body.

While these differences are interesting they do not change the process of recovery for men and women. Massive energy intake is required to regain weight and to repair damage.