Eating
Disorders
Assessing and Treating Men With Eating Disorders
March, 2004-The occurrence of eating
disorders in men remains relatively rare but consistent. This is true
despite recent research suggesting that male cases are far more numerous than
had been previously thought. This brief article will comment on recent research
findings in this area and describe their relevance to assessment and treatment.
Prevalence
Two studies support the notion that
eating disorders are more
common than had previously been thought (Health Canada, 2003; Woodside et al.,
2001). Woodside et al. (2001) reported on the results of a 10,000-person
community epidemiologic study. Combining full- and partial-syndrome eating
disorder cases for both men and women, the investigators showed an overall rate
of three female cases for every one male case-a far cry from the typical 10:1 or
20:1 ratio found in most treatment settings. However, this study assessed only
limited Axis II parameters and, as DSM-III-R diagnoses were generated from the
data, the prevalence of
binge-eating
disorder could not be assessed.
More recently, Health Canada (2003) released preliminary results from a
national, face-to-face mental health survey of over 30,000 people performed in
2001 and 2002. This survey assessed for full-syndrome eating disorders and
reported a ratio of male to female cases of approximately 1:5. This was somewhat
higher than the findings from Woodside et al. (2001) but showed many more cases
than might otherwise have been thought. The somewhat higher ratio in the Health
Canada survey is almost certainly related to only full-syndrome cases that the
Woodside et al. survey was too small to allow for.
Nature of the Illness
Studies continue to show that the nature of the illness, when it occurs in
men, is essentially indistinguishable from women. In Woodside et al. (2001), the
sample of male eating disorder cases in the community was compared to female
eating disorder cases in the same sample and a sample of 3,769 unaffected males.
There were no significant differences in any variables relating to illness
severity. As mentioned, both full- and partial-syndrome cases were included.
Previous research showed that partial-syndrome cases did not differ from
full-syndrome cases on most eating disorder variables; there was an excess of
partial-syndrome cases of bulimia nervosa in males compared to females. This may
have been an artifact of the small sample size in the study.
Other studies have examined differences in personality between men and women
with eating disorders (Fassino et al., 2001; Woodside et al., submitted for
publication). These studies demonstrated that men with eating disorders had
lower scores on the Temperament and Character Inventory (TCI) for Harm
Avoidance, Reward Dependence and Cooperativeness. Our study also showed lower
perfectionism in male cases.
Response to Treatment
There is an extreme scarcity of literature regarding differential response to
treatment in men with eating disorders compared to women. The literature that
does exist suggests that men and women receive similar benefit from treatment
for their eating disorder (Woodside and Kaplan, 1994). This is an area that
deserves much more attention.
We are thus left with a confusing situation: Men appear to suffer from eating
disorders with a higher frequency than would be thought, based on data obtained
from clinical settings, despite having a similar illness and similar responses
to treatment. What could explain these findings and what impact might such
explanations have for practicing clinicians?
Why are fewer affected men identified in formal treatment settings? One
possible explanation is that men simply do not see themselves as being at risk,
and therefore dismiss or ignore symptoms that might be indicative of an illness
requiring treatment. For example, a young woman who is overeating and vomiting
would be quite likely to self-identify as having bulimia nervosa, due to the
large amount of public attention that has been paid to these conditions. A young
man with similar symptoms might simply think that his eating habits are bad or
that he drinks too much, not paying too much attention otherwise. Friends-both
male and female-might also have a lower index of suspicion for a formal eating
disorder and attribute symptoms to other causes.
A young man who is losing weight might be identified as having a drug problem
or AIDS, rather than suffering
from anorexia nervosa. Again, neither male nor female friends might make the
connection between the outward symptom and the presence of an illness, simply
because of the societal expectation that individuals with eating disorders are
all female.
The relevant message for clinicians is to be aware that men are at risk for
eating disorders and to include a history of eating-related behaviors in their
exams. This is particularly important in the identification of bulimia nervosa,
which may have no outward symptoms.
Men may also be worried about assumptions about sexual orientation. There is
a long controversy about the extent to which homosexual men might be
over-represented among those males with eating disorders. To date, all the
research done on this question has been in clinical samples and may be biased.
Studies from these clinical populations have cited high rates of homosexual
orientation (Herzog et al., 1984). Unfortunately, information on sexual
orientation was not available for the Woodward et al. (2001) study. We are
attempting to discover whether this information is available for the Health
Canada (2003) study. Thus, there is no definitive answer to the question of
sexual
orientation and eating disorders.
One idea that has been raised to explain these findings is that homosexual
men may be less reluctant to self-identify as suffering from an eating disorder
because of the different focus on weight and shape in the homosexual male
community. They may also simply be more willing to access treatment once they
have identified their behaviors as troublesome. For the clinician, the most
important issue to remember is to reassure heterosexual male patients that the
diagnosis of an eating disorder does not require any specific sexual orientation
and that no assumptions will be made about sexual orientation, one way or the
other.
Men may be unwilling to enter treatment programs that are mainly for women.
There is a fairly good awareness among both men and women about the extent to
which eating disorders are a problem for women, which includes the idea that all
available treatment programs are for women only. Alternately, men may experience
a general reduction in help-seeking behaviors that is independent of diagnosis.
I am unaware of any treatment programs specifically for men, aside from an
occasional support group. Unfortunately, the
lack of male-specific treatment
programs reinforces the idea that treatment is only for women.
I am equally unaware of significant programs that exclude men. The reduced
focus on treatment of men is usually related to the small number of men
presenting for treatment--so a circular arrangement occurs. While there is
little formal research on treatment outcome for men, most senior clinicians will
indicate that the outcome appears to be similar for both men and women. I tell
prospective male patients that the usual role a male patient ends up taking in a
treatment group is that of a brother--someone the female patients trust and feel
close to, but with whom there are clear boundaries. In my treatment programs,
men are included in all aspects of the program when admitted. In fact, our
female patients have told us that they appreciated having a male peer's input on
issues pertaining to relationships, appearance and so forth.
For the clinician, the most important messages for male patients are that the
treatment is the same for men and women and that men are generally welcomed,
both by the treatment team and by other members of the treatment group. It is
worth reassuring a male patient that he is likely to be accepted by the group
and will find a comfortable place there.
Are there any differences in the treatment a male patient should receive?
Generally, the answer to this question is no. Men respond to the same types of
interventions as do women, to the best of our knowledge. There is sometimes a
perception that men who are affected have more severe illness. This is probably
due to the fact that when large numbers of male patients are compared to female
patients, there are no significant differences.
Clinicians will of course be aware that men and women are socialized
differently in Western culture, and while the overall process of eating disorder
cognitions is the same, the precise content may be slightly different. For
example, men are more involved in competitive sports and thus will talk more
about their concerns about athletic prowess.
It is important to remember that while rates of sexual abuse are lower in men
than in women, that about 10% of men with an eating disorder reported a history
of sexual abuse (Woodside et al., 2001). As is the case with women, such an
occurrence may be an important factor in the etiology of the eating disorder.
Summary
The occurrence of eating disorders in men appears to be more common in the
community than had previously been thought. There are a number of factors that
may keep men out of treatment, ranging from lack of self-identification to
perceived stigma. Once in treatment, men appear to respond in much the same way
as do women.
Source: Psychiatric Times, March 2004, Vol. XXI, Issue 3
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