Why do so few males seek eating disorder treatment?

By Andrew Walen, LCSW-C, LICSW, CEDS

It took 20 years for me to get help for my eating disorder. The signs were there all along – body image disturbance, restriction, compulsive exercise, food preoccupation, binge episodes, guilt, shame, depression, anxiety, and the like. I saw therapists and med providers in Baltimore, D.C., Boston, and Nashville. Some were attached to world famous facilities, yet none made the diagnosis. I was a man, and that seemed to mean I was simply “depressed.”

By age 30, I finally found someone who identified my struggle. That someone was me. I was a graduate student studying to be a clinical social worker. Discussing the issues of eating disorders with classmates, it became clear my eating disorder thoughts and behaviors began about age 10 when I became a regular target for bullying. I spent much of my pre-adolescence emotionally self-soothing with food and the result was a round belly that attracted ridicule. I was crash dieting soon after, cycling into binge behaviors and more restriction.

The teasing I experienced throughout my teen years included being called a “fat-ass” and other similar terms. In middle school, I began to be ridiculed for developing male breasts; I was nicknamed “Tits” on my high school swim team. By my senior year, the binge and restrict cycles became more and more tied to my emotional dysregulation, poor body image and negative self-worth. I was weighing myself daily, then multiple times a day, and after I would go to the bathroom to see if the number changed. The fixation was not on weight loss though. Let me be very clear, the fixation was if I was masculine enough.

My father and mother both wanted the best for me, but rather than tell me it’s okay to have the body I had, they both encouraged weight loss and more time in the gym. I don’t blame them though. My mother grew up the daughter of a Yiddish Theater actress prized for her petite femininity, something my mother was not. My mom developed anorexia at age 12 and struggled her whole life with the same undercurrent of unworthiness due to the body she had. My father had to learn to be the tough kid who beat people up to get respect as he moved to a new school every year of his childhood until he was 15. Being a man meant being tough, macho, strong, driven, and sexually desirable. A soft body was none of those things to my father, and he worked at being a rugged man his whole life. My father’s sister dealt with the constant relocation differently, and anorexia became a pervasive part of her life from her teen years on.

I was hit with a double dose of genetic predisposition and aesthetic acculturation. I didn’t want to be thin though; I wanted to be built like my father. I wanted round biceps, strong jaw, a V-shaped swimmers’ body, and to be considered sexually desirable by women. I wanted to be the definition of masculine I saw in mother’s Playgirl magazines and underwear ads featuring the Orioles pitcher Jim Palmer.

I spent years trying to force my body to be something it wasn’t genetically meant to be. And because I couldn’t achieve the unachievable, I labeled myself weak and worthless and fat – terms that played on a loop in my brain. My therapists kept saying I was depressed and perhaps I should work out more and eat healthier, which only fed my eating disorder further.

Once I finally concluded it was more than depression that I needed help with, my search for treatment hit an immediate roadblock. No programs existed that would accept me because I was a man. No support groups would let me participate because I was a man. I found a couple of outpatient providers, and only one was able to work with my financial limitations being a new dad, a grad student, and broke. I had to make my own way to cobble together treatment resources, scraping the far corners of the nascent internet to find anyone who resembled my experience. I found a book or two and a few journal articles, but not much else. The path to recovery was one I had to forge on my own.

Over the course of my career, I have learned how common my experience is. Males suffered, but were misdiagnosed and/or turned away from care at incredible rates. They were also emasculated by peers and loved ones, often meant playfully, but damagingly nonetheless, with admonitions to “man-up” and put on your big-boy pants. Others were told: just eat; exercise through the pain; binge eating is normal, worrying about it is for girls; purging is normal, wrestlers do it all the time; just exercise off that Big Mac; I wish I had abs like that. Gyms are filled with men who normalize compulsive exercise, a fixation on muscle size, definition and striations, and abuse of appearance and performance enhancing drugs. Our expression of “normal” manly behavior seems to be normalizing eating disorder pathology.

Males develop eating disorders, period. Latest statistical models suggest it affects millions of American males every year. So why do we see so few in treatment? Because so few are properly assessed and diagnosed; the behaviors are often seen as “normal” in popular culture; the stories they often read online are about being the “only man in the treatment program” and feeling awkward, different, and otherized; and in our hyper-masculine culture, males evade care to avoid being chastised for being feminine, gay, or weak.

What can we do then? First, I encourage everyone to recognize there’s a language difference when talking about eating disorders that misses the mark where men are concerned. Men don’t see their eating disorder behaviors as framed in thinness and weight. Rather it’s about masculinity defined by prowess, power, exceptionalism, and its manifestation in physical norms. And we have to honor the fact that men do have deep feelings and thoughts, but many are not given a chance to be heard in a field that has only recognized women’s issues and needs. In my work, I’ve encountered males across the globe who want and need to talk about their heart and their soul. They just need a safe place to share and for someone to listen and relate.

We need to educate families, providers, and the public how males with eating disorders think and speak differently about their eating disorder. We need to demonstrate the unique differences and similarities in how these diseases develop and fester. We need to normalize seeking treatment. And we need to have more men speak up and say recovery is possible. I hope you and your loved ones will keep reading and discovering more about males and eating disorders so more men will seek the treatment they need and deserve.

Andrew Walen, LCSW-C, LICSW, CEDS, is the Founder and Executive Director of The Body Image Therapy Center, VP of Eating Disorders Treatment for Refresh Mental Health, and the Senior Advisor on Males with Eating Disorders for the National Eating Disorders Association.