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Eating Disorders The Journal of Treatment & Prevention

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Including the excluded: Males and gender minorities in eating disorder prevention

Leigh Cohn, Stuart B. Murray, Andrew Walen & Tom Wooldridge

To cite this article: Leigh Cohn, Stuart B. Murray, Andrew Walen & Tom Wooldridge (2016) Including the excluded: Males and gender minorities in eating disorder prevention, Eating Disorders, 24:1, 114-120, DOI: 10.1080/10640266.2015.1118958

To link to this article: http://dx.doi.org/10.1080/10640266.2015.1118958

Published online: 15 Dec 2015.

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THE LAST WORD

Including the excluded: Males and gender minorities in eating disorder prevention Leigh Cohn, Stuart B. Murray, Andrew Walen, and Tom Wooldridge

National Association for Males with Eating Disorders, Naples, Florida, USA

By operating under the outdated premise that eating disorders (ED) predo- minantly affect females, prevention efforts have been disproportionately aimed at girls and young women. This article will show how one-sided the research and program development has been, and present recommendations for how to expand curricula and policy to be more gender inclusive. Ultimately, ED and related issues (e.g., body image dissatisfaction, obesity, comorbid conditions, weight prejudice, etc.) cannot be expected to decrease unless everyone is involved, regardless of gender. We wouldn’t only inoculate girls for measles—preventing ED across the board is the only fully effective approach.

Adolescent girls: The face of a disorder

Try telling a stranger that you specialize in “males and eating disorders,” and the typical response is, “You mean like those poor starving girls. I didn’t know guys got eating disorders.” It’s infuriating, but somehow worse when it is members of the ED field thinking that way. This kind of ignorance starts with inaccuracies. Since the 1980s, the oft-repeated, not-cited statistic has been that 10% of individuals with ED are male. Erroneous to begin with, the number originated from a study that counted 241 people referred for ED at one hospital over a period of 3.5 years, prior to 1985. Twenty-four were males, some of which didn’t meet ED criteria, but because it wasn’t clear how many of the women fully met the criteria, the 10% is somewhat vague (Andersen, 1985). The figure does not represent other treatment providers’ admissions or the general population, and it was not replicated. Further, few physicians or members of the general public knew much about ED in the early 80s, and the admissions in those years predated the field’s emergence that soon followed. It is likely that the actual male prevalence at that time was much higher, as became evident in later studies.

Nonetheless, 10% has been parroted in books, professional articles, on ED organizations’ websites, and in popular media for the nearly 30 years, and it

CONTACT Leigh Cohn Leigh@gurze.net Eating Disorders: The Journal of Treatment and Prevention, P.O. Box 2238, Carlsbad, CA 92018, USA.

EATING DISORDERS 2016, VOL. 24, NO. 1, 114–120 http://dx.doi.org/10.1080/10640266.2015.1118958

© 2016 Taylor & Francis

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has minimized the drive for gender equality within the ED field. Usually, the National Eating Disorders Association (NEDA) is attributed as the source, because up until 2015—when Leigh Cohn updated their website’s statistics on males—they published this prevalence figure, although without a refer- ence. Had anyone dug deeper, they would have discovered that, not only was the 10% figure dated and misrepresented (instead of referring to males in treatment, as the study indicated, sometimes it is incorrectly used to indicate general prevalence), it was also always wrong for reasons that persist today. Oftentimes, men do not seek treatment because they are reluctant to ask for help; but beyond that, they are consistently stigmatized by the idea that they might have an adolescent girl’s problem. Men and boys are less educated about ED, so they might not even consider that their behavior (e.g., extreme weight loss, purging, binge eating, compulsive exercise, etc.) is on the ED spectrum. They might actually suffer from a diagnosable ED and think that it is normal behavior. In one study, male patients with anorexia nervosa emphasized the lack of gender-appropriate information and resources for men as an impediment to seeking treatment (Räisänen & Hunt, 2014). Additionally, assessment tests underscore males because they have been written for females (Darcy & Lin, 2012). For example, the Eating Disorders Inventory has a question, “I think my thighs are too large,” which resonates far less for men than women, whereas the Eating Disorders Assessment for Males (EDAM) uses a statement “I check my body several times a day for muscularity,” which is more oriented toward the concerns of males (Stanford & Lemberg, 2014). However, the EDAM was not available back in the 80s and the EDI was the standard. So, let’s forget about that 10% number once and for all!

The best data available (Hudson, Hiripi, Pope, & Kessler, 2007) indicate that males account for 25% of individuals with anorexia nervosa and bulimia nervosa and 36% with binge eating disorder. Further data from pre-adolescent samples illustrates that up to half of those with selective eating are boys (Nicholls & Bryant-Waugh, 2009), which is significant when considering the evidence suggesting that selective eating is often a precursor to the develop- ment of full-blown ED psychopathology in adolescence (Nicholls, Christie, Randall, & Lask, 2001). When it comes to subclinical eating disordered beha- viors, according to a review of numerous studies (Mond, Mitchison, & Hay, 2014), the percentages are even higher for males in subclinical ED (42–45% binge eat, 28–100% regularly purged, 40% endorsed laxative abuse and fasting for weight loss). Perhaps the most illustrative recent data point to disordered eating practices in the community, for the very first time, increasing at a rate faster in males than females (Mitchison, Mond, Slewa-Younan, & Hay, 2013). Okay, if this rising prevalence now means that about 25–50% of individuals with ED are male, shouldn’t we see at least a similar distribution of prevention studies? Doesn’t the absence of prevention studies continue to marginalize the

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male experience of disordered eating, and continue to propagate the notion that eating disorders just don’t bother the boys?

A 2007 meta-analysis described 32 prevention studies, only four (12.5%) of which included boys (Stice, Shaw, & Marti, 2007). Eating Disorders: The Journal of Treatment and Prevention has published 69 articles focused on prevention prior to this current issue, and 54% were exclusively female, and 39% of those that mentioned gender included males. None addressed gender minorities. Only one, “Beauty Myth and the Beast: What Men Can Do and Be to Help Prevent Eating Disorders” by Michael Levine (1994)—in the journal’s second issue—solely addressed males, but only within the context of how they can help females not to develop ED. Actually, when Levine’s contributions are removed, only 34% of this journal’s articles have included males. The authors of a university prevention study summed up the popular thinking of researchers, “Men were not recruited because women are much more likely than men to develop body image disturbances and eating dis- orders (Ridolfi & Vander Wal, 2008).” In other words, the 25–50% of males with disordered eating are insignificant—or the investigators were stuck with the 10% figure.

Incidentally, overall research shows a similar bias. At a session on males and ED at the International Conference on Eating Disorders in 2013, Mark Warren reported that a PubMed search for papers on anorexia nervosa between 1900–2010 showed that men were included in 26% of them. Speaking on the same panel, Cohn stated that “males” were found in fewer than 7% of abstracts between 2000–2012 that referenced “eating disorders.”

This current special issue of this journal includes 12 articles besides this one, and no one else is addressing the importance of including males. Although the authors, many of whom are the field’s foremost experts, offer excellent ideas, they are all overlooking the needs and roles that males play in the ED continuum. Only four even mention males (two of which added information about male prevention after being queried editorially), and the others either ignore gender, which is fine, or use offer feminine examples (e.g., Girls Scouts, sororities, school-based programs for girls, etc.). Again, no one mentions gender minorities.

Prevention amongst high-risk male groups

Male eating disorders and related issues are multi-cultural and exist across age groups, but there are certain specific populations that are particularly at high risk. The types of universal and selected prevention strategies that are described elsewhere in this journal should be gender inclusive, but beyond that, special attention needs to be focused on certain groups. Most school programs have been developed in consideration of risks for girls (e.g., pressure to be thin), but they also need to take into account the concerns

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of boys (e.g., pressure to be lean and muscular); and, lessons, about media literacy for example, should be gender inclusive (e.g., show before and after computer-altered images of women and men). Additionally, there are a few specific populations in which non-female members should be reached.

People who identify as lesbian, gay, bisexual, transgender, and questioning (LGBTQ) are at higher risk of developing an ED (Brown & Keel, 2012). While approximately 3% of men in the general population identify as gay or bisexual, studies show that they comprise as high as 42% of men in treat- ment. Although globally more heterosexual males have ED, there are a higher percentage of gay males (15%) who are diagnosed (Feldman & Meyer, 2007). The idealized body type of being lean and muscular is particularly desired by gay men, many of whom suffer from body dissatisfaction, anxiety about appearance, excessive body checking, and negative physical-self evaluation, which all are risk factors for developing an ED. The LBGTQ community is proactive in seeking equal rights and recognition, and concerted efforts within the ED prevention community should be integrated into existing avenues for information and education. For example, university advocates who organize eating disorders awareness education and prevention efforts should coordinate with the LBGTQ Center on campus. Also, beginning at the pre-elementary level, putting an end to bullying (an identified precursor to ED behaviors) and teaching acceptance about gender diversity (including stereotypes as they relate to sexuality) should be a part of every prevention curricula.

Certain athletes are at higher risk for an ED. For example, wrestlers, boxers, jockeys, gymnasts, and long distance runners often lose weight by purging, fasting, and excessively exercising. Some football linemen force feed themselves to gain weight, and many athletes binge and exercise to work off the calories, unaware that their behavior might be considered bulimia ner- vosa. Through decades of prevention work with the NCAA and Olympic Committee, Ron Thompson and Roberta Sherman have led the way toward educating coaches at the college level. They’ve collaborated with adminis- trators, coaches, athletes, and cheerleaders; and, in this journal’s first issue, they contributed an article, “Reducing the Risk of Eating Disorders in Athletics” (1993) in which they outlined risk reduction strategies including deemphasize weight, eliminate group weigh ins, and stop dangerous “weight cutting” behaviors. In 1998, Thompson wrote a “Last Word” editorial in this journal after three wrestlers had died from exercising in saunas—two were wearing plastic suits at the time. He indicated that the NCAA was moving to adopt new restrictions on the use of destructive weight loss techniques, and shortly afterward the NCAA implemented prohibited practices that are still enforced, “The use of laxatives, emetics, excessive food and fluid restriction, self-induced vomiting, hot rooms, hot boxes, and steam rooms is prohibited for any purpose. The use of a sauna is prohibited at any time and for any

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purpose, on or off campus (NCAA, 2013).” In the 16 years after these rules were put into effect, no collegiate wrestler died as a result of unsafe weight cutting practices (Rosenfeld, 2014). While this is evidence that prevention efforts can save lives, the same ideas Thompson and Sherman voiced 24 years ago still need to be more widely implemented from elite levels down to children’s teams. Furthermore, prevention programs must be repeated reg- ularly due to the high turnover rate among coaches, especially in youth leagues, where many of the parents who coach are uneducated about body image issues, teasing, and other risk factors for ED, especially among males.

In the related demographic of body builders, increased research, educa- tion, and prevention surrounding muscle dysmorphia is crucial. The drive for muscularity becomes a compulsion for some men (and some women), who spend excessive hours in the gym and abuse steroids or performance enhan- cing supplements like creatine and protein powders, which are typically increased over time. Trainers, lifters, and fitness club staff, should be edu- cated about harmful consequences (e.g., kidney or liver problems, distorted body image, body objectification, social isolation) and the difference between healthy and unhealthy exercise and eating.

Last but not least, more research and prevention must be devoted to binge eating disorders. The most common ED and affecting far more males than anorexia and bulimia combined, BED, especially how it presents in males, is understudied clinically and is virtually absent in the prevention literature. Many men who can be classified with BED don’t even realize that bingeing isn’t normal guy behavior. Too often it is lumped together with obesity, even when the prevention field is perfectly aware that not everyone who is obese binges and not everyone who binges is obese. The insecurities that men have about their weight and body, sex and money, global fears and archaic definitions about what it means to be a man can result in binge eating for emotional comfort, so men need to be educated about feelings, commu- nication, community, and other areas that may be unfamiliar to them. They also must learn about principles of healthy living, because, frankly, a lot of men have misconceptions about nutrition, fat versus fit, and body/self- empowerment—to name just a few.

Transforming beauty and the beast

Levine’s aforementioned article was directed at how fathers, husbands, broth- ers, and other men can help women. In the abstract, he writes, “Eating disorders are in part created and maintained by the inter-related phenomena of male-female relationships…” but he is clearly most concerned about the women, “I am frightened—for my daughter, my wife, my female colleagues…” instead of men, including his sons. Although the article is monumental as the only prevention article that purely spoke to men—even though he ignored

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those with ED—it misses an important point: when males are more sensitive to the needs of females, the better it will be for both sexes, and visa versa.

This is certainly not a revolutionary concept—compassion for everyone— but the ED prevention field has been too female centric. If it is good prevention strategy to teach a class of high school girls that pictures of thin models are digitally enhanced, can lead to poor body image, and are emo- tionally manipulative; then, shouldn’t boys be instructed in the same lessons too? In that instance, boys would discover that these kinds of sexually objectifying images are not only demeaning and harmful for the girls, but that their own preconceptions about beauty were being influenced. And, shouldn’t they all be shown how the men on magazine covers have their muscles highlighted with body makeup and Photoshop, and that those models were possibly abusing anabolic steroids or supplements in the pursuit of those six-pack abs and ripped chests? Shouldn’t women be told that men are insecure about their bodies in profound ways, that they engage in stigmatized behaviors that fill them with shame and other feelings that they have difficulty expressing in words. Women are learning to become empow- ered with tools like mindfulness, self acceptance, body love, media literacy, and self-respect; but, their insights to self awareness are only going to be truly effective if men learn these same methods for their own benefit, as well as for the women in their lives. That’s how both men and women can find support, eliminate stigmas surrounding ED, and experience an overall better life.

Society must move away from the paternalistic hegemony, and nowhere is that more true than in the arena of ED. That women have been victimized by men is not breaking news. Most women with ED have had negative experi- ences with men (e.g., father hunger, cruel words, sexual abuse) in one way or another, but so have males with ED! While feminism has campaigned so ardently for gender equality, the continued focus on female approaches to ED prevention and treatment—at the exclusion of non-females—may be funda- mentally anti-feminist. Beyond that, a new paradigm must emerge that reflects a society with increasing gender equality. While the LGBTQ com- munity makes inroads in areas such as gay marriage, and women are making strides in corporate boardrooms, a new heterosexual male must also manifest itself. He has to give up the chauvinistic mentality and develop underutilized cognitions (i.e., his feminine side) to exist more evenly in the balanced utopian world we’d all like to see. While that world may not be realistically possible, we should, nevertheless, strive toward that goal.

References

Andersen, A. (1985). Anorexia nervosa and bulimia: Their differential diagnoses in 24 males referred to an eating and weight disorders clinic. Bulletin of the Menninger Clinic, 49(3), 227–235.

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16 http://dx.doi.org/10.1002/eat.v45.6http://dx.doi.org/10.1080/10640266.2012.715521http://dx.doi.org/10.1002/(ISSN)1098-108Xhttp://dx.doi.org/10.1002/(ISSN)1098-108Xhttp://dx.doi.org/10.1016/j.biopsych.2006.03.040http://dx.doi.org/10.1080/10640269408249106http://www.jeatdisord.com/content/1/S1/O23http://dx.doi.org/10.1016/j.chc.2008.07.008http://dx.doi.org/10.1177/1359104501006002007http://dx.doi.org/10.1177/1359104501006002007http://dx.doi.org/10.1136/bmjopen-2013-004342http://dx.doi.org/10.1080/10640260802370630http://www.ncaa.org/health-and-safety/sport-science-institute/weight-loss-wrestling-current-state-sciencehttp://www.ncaa.org/health-and-safety/sport-science-institute/weight-loss-wrestling-current-state-sciencehttp://dx.doi.org/10.1146/annurev.clinpsy.3.022806.091447http://dx.doi.org/10.1080/10640269808251257http://dx.doi.org/10.1080/10640269808251257http://dx.doi.org/10.1080/10640269308248268

• Adolescent girls: The face of a disorder
• Prevention amongst high-risk male groups
• Transforming beauty and the beast
• References

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