Josh was a short, skinny, 16 year old high school senior. He had excellent grades and his heart was set on going to the same major university that his older brother attended. Josh’s parents were pleased with his good grades but they were starting to be concerned about his preoccupation with “healthy eating” and exercise. He started by cutting out desserts, then anything sweet, and then all processed foods. At the same time he spent ever-increasing hours swimming laps in the pool. Several months later, his parents brought him in to see me after he’d been hospitalized and had spent three weeks in an inpatient eating disorder unit.
While Josh’s parents were concerned about his eating habits and preoccupation with swimming, they never recognized that their son was anorexic until the family physician alerted them to the dangers of Josh’s behavior. If Josh had been female, it’s likely that his parents would have recognized the disordered eating before it required hospitalization. Josh’s parents weren’t alone in failing to recognize anorexia in males. Until the 1980’s anorexia nervosa was thought to be limited to females. Current estimates are that about ten percent of anorexics are male. The belief that eating disorders are limited to females may increase the shame that male sufferers experience making them less likely to acknowledge their disorder and seek treatment.
A study of over 5,500 adolescent males that was published last month in JAMA Pediatrics found ten percent were excessively concerned about their weight, muscles, and physique. Although these concerns, by themselves don’t indicate an eating disorder, the findings suggest that males may be subjected to similar pressures about weight and body image as females. Unfortunately, parents and clinicians may not recognize that a boy’s efforts to “get healthy” or “build muscle” may result in unhealthy practices like following fad diets, using growth hormone derivatives, anabolic steroids, bingeing and purging, or even starving.
The study followed the adolescent boys and young adult men over an 11-year period. The results showed that, even without an eating disorder, males with high concerns about thinness were more likely to develop depressive symptoms, while males with concerns about both thinness and muscularity were more likely to use drugs, and binge drink.
Although anorexia and bulimia are as dangerous for males as they are for females, there are some differences in presentation that make it more difficult to identify eating disorders in males. Whereas women may purge or starve in order to avoid appearing fat, men may be less concerned about being fat but rather they would be more motivated to increase their muscularity, for example by developing ”six-pack abs.” Parents and health professionals might be concerned when a normal weight or underweight female is dieting and preoccupied with weight loss. In contrast, a boy or teen’s desire to develop muscles or improve his physique would typically be seen as reasonable and might not arouse suspicion even if the methods he used were extreme.
Fortunately, with inpatient treatment and outpatient psychotherapy Josh was able to curtail his extreme eating and exercise behaviors and develop a more positive body image. If there had been increased awareness of eating disorders in males, it’s likely that his unhealthy behaviors could have been identified earlier so that hospitalization wouldn’t have been necessary. If you’ve got a son who is excessively preoccupied with his weight and muscularity consider the possibility that this may be associated with depression or perhaps a precursor to an eating disorder.