What comes to mind when you think of Anorexia Nervosa? Perhaps you envision the thinly sculpted, svelte models of Milan Fashion Week. As their slim frames are accentuated by designer ensembles heavier than themselves, they are weighed down by an unrelenting sense of cultural conformity to modern beauty standards. You may recall that one Dr. Phil episode you landed on while channel surfing. The one where a teen girl’s deprecating perception of herself manifested into full-blown starvation. In true TV-fashion, just one pep-talk from her parents and Dr. Phil led to a tidy happy ending of the episode, with the girl on her way to recovery at “The Ranch.”
To my innocent, unperturbed mind, this episode served as my first exposure to the concept of body dysmorphia. These mainstream representations are what would have come to mind if I were asked this question four years ago, when I was distanced and detached from the personal realities of Anorexia Nervosa. Now, familiar feelings of helplessness resurface as I recount the ashen, haunted visage of my younger brother. He was just 13 years old when he was diagnosed with Anorexia Nervosa, a mental illness I had initially internalized as a women’s illness.
It’s not just me who held this misconception.
Due to the lack of medical literature on males with eating disorders, his pediatrician only saw the signs and intervened when heart complications arose. Many adolescent males in the United States are not receiving sufficient treatment for anorexia nervosa, due to the influence of systemic gender constructs over medical literature, clinical diagnosis, and proper intervention protocol.
“Eating disorders” is an overarching term that is characterized by the National Institute of Mental Health (N.I.M.H.) as “a serious and often fatal illness associated with severe disturbances in people’s eating behaviors and related thoughts and emotions.” This encompasses anorexia nervosa, bulimia nervosa, and binge-eating disorder. Those who suffer from anorexia display symptoms of “emaciation, extremely restricted eating, intense fear of gaining weight, excessive exercise, and distorted body image.” People with anorexia are dangerously underweight and often exhaust additional means to lose weight, such as vomiting and excessive laxative use.
According to NIMH, “anorexia nervosa has the highest mortality rate of any mental disorder.” In 2014, males accounted for 25% of all Anorexia Nervosa cases and they are reportedly at a greater risk of death since their symptoms are recognized later on in the progression of the illness. When you are an adolescent male with anorexia nervosa, you fare far worse.
Since anorexia is expressed uniquely in adolescents, it is even more difficult to detect the signs and symptoms of anorexia early on. It is difficult to quantify the extent of this underrepresentation with limited empirical data on males with anorexia. The exclusion of males from research is indicative of the inherent gender bias that exists to prevent exploration of the phenomenon. However, current research allows us to conclude that anorexia nervosa is most often developed in one’s teen and young adult years. A national study conducted by The Society of Biological Psychiatry in 2017 found the median age of symptom onset to be 15 years old, and none of the participants were diagnosed with anorexia beyond their mid-twenties. Since anorexia is most common in adolescents, this highlights the significance of studying the phenomenon in adolescents and the specialized impacts over developmental health.
An analysis conducted by pediatric eating disorder specialists with the European Eating Disorders Review found the consequences of malnutrition and related medical complications to be most severe in youth. Adolescence heralds a period of profound growth and maturation with many contending influences: “the physical changes of puberty, the social changes associated with increased peer influence, and the increased opportunities to engage in both maladaptive and adaptive decisions—all against a backdrop of intensified emotional reactivity.” As a result, the health impacts in youth can become more profound as patients go undiagnosed in their physical and mental years of development and their situations become graver. More research and awareness into adolescent male symptomatology is crucial for effective and timely intervention.
The issue of underrepresentation is also compounded by widespread misconceptions of how anorexia is exhibited in males. In the midst of contemporary feminist campaigns, eating disorders are grossly homogenized as a women’s issue. It is in vogue to embrace body positivity and female empowerment, heralding an end to vapid perceptions of self worth and extensive literature into eating disorders has demystified the phenomenon for women. But as the rigid patriarchal construct of feminine ideality is dismantled, their progressive movement is undermined by a lack of exploration into hegemonic masculinity. As long as mental health issues are stigmatized amongst men, their experiences will be excluded from the narrative.
Gendered social constructs exacerbate the disparity in eating disorder recognition and intervention. These constructs, referred to as “masculine norms,” are represented through hyper-masculine behaviors, portrayals of dominance and strength, heteronormative stereotypes, and emotional restraint. Mental health concerns for men have been buried by efforts to maintain masculine norms in society, whether deliberate or unintentional. Shortcomings in emotional regulation among men have made it difficult to acknowledge mental illness diagnoses, because they are often viewed as an affront to their masculinity and strength.
Not even medical professionals are immune to these internalized masculine norms. The most widely circulated measures for anorexia diagnosis used in clinical practice are developed and normed for females. Men were precluded from decades of anorexia research, so the standards for intervention were initially framed around females with anorexia and have remained today. The psychopathology of anorexia is found to differ in both males and females, yet the diagnosis criteria propagated in the medical and research community undermines the heterogeneity of symptom expression. Such differences in psychopathology were proven by studies that compared the drive to maintain “thinness” in anorexic men and women, and the difference in perfectionism and maturity fears in males with and without anorexia.
Anorexia manifested itself in the females as a sense of body dissatisfaction and an insatiable compulsion to be thin, while the root of the problem for males was not based on thinness, perfection, or any of the other observed struggles for females with anorexia. Rather, the idealized male body image is purported to be lean, where thinness and lack of body fat merely accentuate a lanky, muscular physique. As a result, the symptoms of males go unrecognized because only female symptoms and pathologies are universally recognized and applied in clinical practice.
In order to resolve the issue of underdiagnosis, we must modify the parameters for diagnosis with broadened, more encompassing criteria to identify anorexia. Current policies to identify anorexia are defined by an overreliance on stereotypically feminine indicators, which precludes male psychopathology from medical evaluation.
Universal adoption of the 50-item Eating Disorder Assessment for Men (EDAM) as an official version of the Eating Disorder Examination seems like a practical solution. EDAM was created by psychological researchers Stevie Stanford and Raymond Lemberg through a comprehensive literature review that includes the male presentation of “food issues, weight concerns, exercise issues, body image/appearance concerns, and disordered eating habits.” The current assessment is not designed to identify males with anorexia and its efficacy in diagnosing males has been disproven. Compared to the overarching Eating Disorder Examination, which serves as the national standard utilized by physicians to diagnose anorexia nervosa, EDAM yields the greatest accuracy in predicting the presence of anorexia in men. By universally accepting this diagnosis model, and applying it conjunctively with the official assessment for adolescents, the American Psychiatric Association would bridge the information gap that inhibits adolescent males from receiving proper mental health treatment.
Greater emphasis on the male-only treatment group model provides hope for recovery. Adolescent males who participated in male-only rehabilitation programs have demonstrated success in transcending stigma over masculine norms, which allowed them to foster an accepting environment conducive towards the healing process. In a study conducted in Australia, the greatest success in recovery was realized by challenging hegemonic masculinity. Specifically, participants described their role in examining the positive and negative examples of masculinity to be the most conducive in the recovery process.
To divert from a traditionally female-centric recovery process, men should have their own proverbial ranch like in Dr. Phil, where the male experience is accepted and men can overcome their own unique struggles with anorexia.