Eating Disorders in Men & Boys
The Development of Eating Disorders in Males
The eating disorders of men are often overlooked. Eating disorders are often considered a young female illness, but the reality is that anyone of any age or sex can suffer from an eating disorder. Men and boys suffer from their own body image issues, which may manifest as an eating disorder, with its own risk factors, body ideals and presentation unique from most women and girls.
Body Image of Men & Boys
Men and boys differ from their female counterparts when it comes to body image. Males have a wider range of body ideals than females and perceive their weight differently, both contributing to how their eating disorders develop.
Male Body Ideals
Men and boys experience a wider variety of body ideals than women and girls. While females tend to only desire thinness, males desire a range of physique goals, including very thin, the extremely muscular and the lean muscular, which is the most commonly desired body type among men.1
From a young age, the media showcases images of impossibly fit men with “washboard abs” and lean muscularity as the male ideal, which has been shown to cause negative self-comparisons in consumers, with the goal to sell products to improve health, appearance, weight, muscularity and shape.1
Perception of Weight
Unlike girls, who tend to perceive themselves as fat at more than 15-18% below population norms, boys learn to perceive themselves as fat at slightly above population norms, which is when adolescent males who develop an eating disorder are most likely to begin their dieting.2
Because of the decreased pressure for boys to diet compared to girls, they tend to only do so under certain conditions:
- To avoid being teased again as they were for childhood obesity
- To increase sports performance
- To avoid developing similar weight-related medical illness as their father
- To improve a gay relationship1
While women tend to be dissatisfied with their body from the waist down, men tend to be dissatisfied with their body from the waist up.
Risk Factors for Eating Disorders in Males
Risk factors for men include sexual orientation, sports, hobbies and occupations.
Gay & Bisexual Orientation
Between 16-20% of males with eating disorders have a gay orientation, significantly higher than the population as a whole, but still a minority of men with eating disorders.1
For gay men, a higher BMI, peer pressure, gender role conflict and lower levels of masculinity are associated with greater body dissatisfaction and disordered eating behaviors.3,4
Bisexual men are more likely to engage in unhealthy weight control compared to heterosexual and gay men. The use of dating apps is also a risk factor for both gay and bisexual men, likely due to the added pressure to achieve a certain body type to attract a sexual partner.5
Sports, Hobbies & Occupations
Males who participate in sports, hobbies or occupations that incentivize thinness for appearance and/or performance are more likely to develop disordered eating behaviors than their peers.11 Sports are a well-studied risk factor for development of any eating disorder, with 19% of male athletes struggling with disordered eating behaviors and 8% have been diagnosed with an eating disorder.6 Elevated rates of eating disorders are found in sports like wrestling, gymnastics, swimming, track, equestrian and football.9,7 Athletes with eating disorders can also be more difficult to identify and diagnose, due to stigma or a concern their athletic season will be disrupted by treatment.
Male Eating Disorder Statistics
Males with eating disorders have a different experience than their female counterparts. Men and boys are often undiagnosed and experience male-specific stigma, which may impact their desire and ability to receive treatment.
Prevalence & Underdiagnosis
It’s commonly stated that males make up 10% of those with eating disorders, a statistic that only captures presentations at clinics and hospitals, which significantly underestimates the prevalence of eating disorders in men and boys.8
Ratios of 3.6:1 (female:male) are found through population-based surveys, and an almost equal prevalence is found when female-based diagnostic criteria is removed and behaviors specific to males are considered. The most recent community-based study reports a ratio of 2-3:1.9Subclinical symptoms of eating disorders are also equal among males and females.9
However, more males are receiving treatment than ever before. From 1999 to 2009, hospitalization of males for eating disorders increased by 53%.10
Age of Onset for Males
Males with eating disorders typically fall into three age categories:
- Child onset before 12
- Preteen through early twenties
- Young men and mature adults11
The issues that prompt dieting and disordered eating in these populations varies greatly. Very young boys often express issues at home, like family conflict, moving or a change in the family dynamic, while adolescent men express difficulty with individual identity and wanting to improve aspects of their life like relationships, sports performance, entering the military or preventing weight-related illness.7
While eating disorders are found across ages, most eating disorders in males develop in the teenage years or early twenties.7However, dissatisfaction with body image can begin as early as six years old, with 32.6% of six year-old boys desiring to be more muscular and 20.8% desiring to be thinner.12
Males with eating disorders are often stigmatized for their condition. There is a concern and shame among patients that they will appear less masculine for having a “girl’s disease” or “gay disease,” which may delay seeking treatment.
Additionally, there remain health professionals who are uneducated about eating disorders in males and do not consider diagnosing males with eating disorders. Some programs may not even accept male patients, further stigmatizing eating disorders in males.
The Presentation of Eating Disorders in Men
The presentation of eating disorders in men is different from the presentation of women, primarily through many patients’ drive for muscularity rather than thinness.
Muscularity-Driven Eating Disorder
Muscularity-driven eating disorder (MDED) is a term for the combination of abnormal eating patterns and excessive exercise with the intent to achieve greater muscularity, with the fear of being too small. MDED is not a diagnosis.
In the last twenty years, numerous studies have focused on the drive for muscularity in males dissatisfied with their body image. In a survey of almost 15,000 young adults, 22% of males and 5% of females reported muscularity-focused disordered eating behaviors.13 Males are much more likely to desire increased muscularity than females but may also have a desire for thinness. While females tend to have a fear of gaining weight, males do not necessarily object to weight gain if it’s associated with increased muscle mass, more define muscles or lower body fat.11
Muscle Dysmorphia versus Muscularity-Driven Eating Disorder
Many individuals refer to the combination of abnormal eating patterns and excessive or compulsive exercise as muscle dysmorphia. But muscle dysmorphia, a form of body dysmorphic disorder, doesn’t capture the full picture of MDED. Muscle dysmorphia only focuses on the inaccurate perception of smallness, without accounting for the abnormal eating patterns and excessive exercise of MDED.4
MDEM has also been referred to as “bigorexia” or “reverse anorexia nervosa,” however both terms are linguistically awkward.
Anorexia Nervosa & Bulimia Nervosa in Men
It’s estimated that 25% of those with anorexia nervosa and bulimia nervosa are male.14 However, this number could be higher due to underdiagnosis and stigma.
Presentation of anorexia nervosa and bulimia nervosa in men is similar to women, as men restrict their food intake or engage in rigid food rules. Where men differ from women is motivation. Women restrict their food intake to achieve the thin ideal, whereas men may either restrict to achieve thinness or to become leaner but still toned, also known as “cutting (weight).”
Binge Eating Disorder
Binge eating disorder (BED) is the most common eating disorder diagnosis, with 36% of those with BED are men and boys.14
Medical Complications in Males
Most of the medical complications for eating disorders are shared by males and females, with low testosterone being an exclusive complication present in male eating disorder patients, causing issues like gynecomastia and infertility.
Excessive exercise, particularly when it occurs alongside prolonged calorie restriction can cause a disruption in the male gonadal axis. Diminished LH fails to stimulate Leydig cells in the testes to produce testosterone, causing low testosterone levels, lowered sex drive and reduced sexual function.4,5,15 Low testosterone can lead to fatigue, decreased muscle mass and reduced bone density.
This is a condition where the male breast tissue becomes enlarged. This can occur in males with eating disorders due to hormonal imbalances, specifically decreased testosterone levels.16
Low testosterone and malnutrition can cause a decrease in sperm count and quality, potentially leading to fertility issues.17
Other Highlighted Conditions
There are other conditions which may not exclusively occur in men, but impact men uniquely. These include osteopenia and osteoporosis, cardiovascular complications, muscle weakness and atrophy as well as co-occurring mental health issues.
Osteopenia & Osteoporosis
Many providers may not think to consider osteoporosis in association with a male patient because lower bone mineral density is associated more with women in general medicine than men. However, males with eating disorders who are underweight for at least six months experience more osteoporosis than their female counterparts.18,19 Contributing factors for osteoporosis in men may include low testosterone, diminished calcium intake, lowered body weight, elevated cortisol and possibly other factors.7 Male patients with eating disorders should be tested for low bone mineral density using a DEXA (dual x-ray absorptiometry) scan.
Malnutrition and electrolyte imbalances put individuals with eating disorders at an increased risk of cardiovascular complications, including an irregular heartbeat, low blood pressure and heart failure.20 The risk of cardiac arrest, arrhythmias and heart failure is higher in males with anorexia nervosa than females with anorexia nervosa.21
Muscle Weakness & Atrophy
Men with eating disorders may experience muscle weakness and atrophy due to inadequate nutrient intake and excessive exercise
Mental Health Issues
Men with eating disorders are at a higher risk for developing other mental health disorders than their peers. Men with eating disorders are more likely to suffer from depression, anxiety, and substance abuse.22
Eating Disorder Treatment for Men
The core principles of eating disorder treatment are fundamentally the same for all genders. The main objectives are to restore the individual to a healthy weight, treat any psychiatric issues related to the eating disorder (such as anxiety, depression or distorted body image) and reduce or eliminate behaviors or thoughts that lead to insufficient or excessive eating and exercise.
Treating Medical Complications in Men with Eating Disorders
The medical treatment track for males doesn’t substantially differ from that of females, aside from treating a select few complications.
Nutritional Rehabilitation in Males
The typical goal for weight restoration in an inpatient setting is 3-4 pounds per week and 1-2 pounds per week in an outpatient setting. Calorie intake starts at 1,400-1,800 kcal/day and can be increased by 300-400 kcal every 3-4 days, and should be continuously evaluated based on the rate of weight gain. Male patients generally peak at 4,000 kcal/day. Additionally, weight gain can be supported with liquid supplementation in the early stages of refeeding.11
Patients experiencing severe eating disorders or malnutrition are at an increased risk of developing refeeding syndrome during their nutritional rehabilitation and weight restoration. Make sure to monitor lab values of phosphorus, potassium, magnesium and other substances for signs of refeeding syndrome.
Treating Osteopenia & Osteoporosis
Males with osteoporosis should be treated through weight restoration, strength training, restoration of testosterone and restoration of key vitamins and minerals.
At a restored weight, moderate exercise with low-impact weight bearing activities exert force on bone, which can help encourage bone growth. Resistance training is especially valuable, as it improves morale; elicits feelings of contribution to goals; results in increased lean muscle mass and less abdominal fat deposits, leading to a decrease in remission and provides a healthy setting to work out with other men.7
Important vitamins and minerals like calcium and vitamin D can be supplemented at 1,500 mg/day and 800-1,00 IU/day, respectively.7
Treating Low Testosterone
Testosterone supplementation is an optional measure to treat low testosterone in men with eating disorders. However, it’s yet to be determined if testosterone replacement or a natural return of levels is more beneficial than the other. Extreme caution should be exercised in the use of testosterone replacement in males who are not close to full height or maximal bone growth, as it can cause premature closure of the bony growth plates.23
Psychiatric Treatment for Men with Eating Disorders
While the core goals and treatment options for men aren’t very different than those from women, treatment may be tailored to address issues that are more prevalent or unique to men.
Male Group Therapy Sessions
Men may benefit more from mixed-gender or male-only group therapy options. In groups that are disproportionately female, the inclusion of male patients can be perceived as threatening or impeding on what’s regarded as a safe space for women. They may also be treated as a stand-in for an abuser. Together these can create an unproductive or hostile space for recovery for males with eating disorders.7 Male-only groups also have the added benefit of decreasing the stigma or perception of atypicality of males with eating disorders, allowing men to discuss gender-specific struggles, the cultural messaging around the ideal male body and build relationships with other men.
Addressing Feelings of Stigma
Men with eating disorders often face societal stigma, as these disorders are frequently and inaccurately perceived as exclusively affecting women. Therapists and other healthcare providers should be sensitive to this and work with male patients to address these issues.24
Incorporating Male Body Image Concerns
Men often face different societal pressures around body image than women, with a greater focus on musculature and leanness. Treatment for men often needs to address these specific concerns instead of defaulting to the female experience of body image found in many eating disorder treatment programs.25
Treating Co-Occurring Psychiatric Conditions
Men with eating disorders are more likely to have co-occurring conditions like substance use disorders. This needs to be addressed by a multidisciplinary treatment team.26
Addressing Treatment Engagement
Some studies suggest that men may be less likely to seek help for an eating disorder due to the stigma associated with these conditions. Healthcare providers may need to use different strategies such as emotion-focused therapy and education on the impact of the muscular-oriented male body image toward disordered eating patterns, ultimately ensuring that men feel engaged, comfortable and understood.27
Treatment Outcomes for Males with Eating Disorders
Males and females respond similarly to treatment, with findings suggesting men have similar or better treatment outcomes compared to women.28 Men also experience a similar remission rate for anorexia nervosa, but a slightly lower remission rate for bulimia nervosa.29 Males with anorexia nervosa also score lower on standardized testing and subscales of the Eating Disorder Inventory, with lower scores on interpersonal distrust and perfectionism.30
- Hobza, C. L., Walker, K., Yakushko, O., & Peugh, J. (2007). What about men? Social comparison and the effects of media images on body and self-esteem. Psychology of Men and Masculinity, 8(3), 161–172. https://doi.org/10.1037/1524-918.104.22.168
- Welch, E., Ghaderi, A., & Swenne, I. (2015). A comparison of clinical characteristics between adolescent males and females with eating disorders. BMC Psychiatry, 15(1). https://doi.org/10.1186/s12888-015-0419-8
- Hospers HJ, Jansen A. Why homosexuality is a risk factor for eating disorders in males. J Soc Clin Psychol. 2005;24(8):1188–201. https://doi.org/10.1521/jscp.2005.24.8.1188.
- Blashill AJ, Vander Wal JS. Mediation of gender role conflict and eating pathology in gay men. Psychol Men Masculinity. 2009;10(3):204–17. https://doi.org/10.1037/a0016000.
- Parker, L. L., & Harriger, J. A. (2020). Eating disorders and disordered eating behaviors in the LGBT population: a review of the literature. Journal of Eating Disorders, 8(1). https://doi.org/10.1186/s40337-020-00327-y
- Freedman, J, S. Hage, and P. Quatromoni. Eating Disorders in Male Athletes: Factors Associated with Onset and Maintenance. J Clin Sports Psychology 2021
- Thiel, A., Gottfried, H., & Hesse, F. W. (1993). Subclinical eating disorders in male athletes. Acta Psychiatrica Scandinavica, 88(4), 259–265. https://doi.org/10.1111/j.1600-0447.1993.tb03454.x
- Sweeting, H., Walker, L. M., MacLean, A., Patterson, C., Räisänen, U., & Hunt, K. (2015). Prevalence of eating disorders in males: a review of rates reported in academic research and UK mass media. PubMed, 14(2). https://doi.org/10.3149/jmh.1402.86
- Mitchison, D., Hay, P., Slewa-Younan, S., & Mond, J. (2014). The changing demographic profile of eating disorder behaviors in the community. BMC Public Health, 14(1). doi:10.1186/1471-2458-14-943
- Zhao, Y., Encinosa, W. Update on Hospitalizations for Eating Disorders, 1999 to 2009. HCUP Statistical Brief #120. September, 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb120.pdf
- Mehler, P. S., & Andersen, A. E. (2022). Eating Disorders: A Guide to Medical Care and Complications (fourth edition). Johns Hopkins University Press.
- McLean, S. A., Wertheim, E. H., & Paxton, S. J. (2018). Preferences for being muscular and thin in 6-year-old boys. Body Image, 26, 98–102. https://doi.org/10.1016/j.bodyim.2018.07.003
- Nagata, J. M., Murray, S. B., Bibbins-Domingo, K., Garber, A. K., Mitchison, D., & Griffiths, S. (2019). Predictors of muscularity‐oriented disordered eating behaviors in U.S. young adults: A prospective cohort study. International Journal of Eating Disorders, 52(12), 1380–1388. https://doi.org/10.1002/eat.23094
- Hudson, J., Hiripi, E., Pope, H., & Kessler, R. (2007) “The prevalence and correlates of eating disorders in the national comorbidity survey replication.” Biological Psychiatry, 61, 348–358.
- American Psychological Association. (2012). Eating disorders and men: Overlooked, undertreated. Monitor on Psychology, 43(2), 56.
- National Eating Disorders Association. (2018). Eating Disorders in Men & Boys
- American Society for Reproductive Medicine. (2014). Fertility: An overview (booklet).
- Andersen, A. E., Watson, T., & Schlechte, J. A. (2000). Osteoporosis and osteopenia in men with eating disorders. The Lancet, 355(9219), 1967–1968. https://doi.org/10.1016/s0140-6736(00)02330-8
- Misra, M., & Klibanski, A. (2014). Anorexia nervosa and bone. Journal of endocrinological investigation, 37(11), 1047-1053.
- Sachs, K. V., Harnke, B., Mehler, P. S., & Krantz, M. J. (2016). Cardiovascular complications of anorexia nervosa: A systematic review. International Journal of Eating Disorders, 49(3), 238-248.
- Kalla, A., Krishnamoorthy, P., Gopalakrishnan, A., Garg, J., Patel, N., & Figueredo, V. M. (2017). Gender and age differences in cardiovascular complications in anorexia nervosa patients. International Journal of Cardiology, 227, 55–57. https://doi.org/10.1016/j.ijcard.2016.11.209
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.”
- Mehler, P. S., & Andersen, A. E. (2017). Eating Disorders: A Guide to Medical Care and Complications (third edition). Johns Hopkins University Press.
- Dakanalis, A., Timko, C. A., Clerici, M., Zanetti, M. A., & Riva, G. (2014). Comprehensive examination of the trans-diagnostic cognitive behavioral model of eating disorders in males. Eating behaviors, 15(1), 63-67.
- Murray, S. B., Rieger, E., Hildebrandt, T., Karlov, L., Russell, J., Boon, E., ... & Touyz, S. W. (2017). A comparison of eating, exercise, shape, and weight related symptomatology in males with muscle dysmorphia and anorexia nervosa. Body image, 21, 1-11.
- Harrop, E. N., & Marlatt, G. A. (2019). The comorbidity of substance use disorders and eating disorders in women: prevalence, etiology, and treatment. Addictive behaviors, 92, 144-153.
- Räisänen, U., & Hunt, K. (2014). The role of gendered constructions of eating disorders in delayed help-seeking in men: a qualitative interview study. BMJ open, 4(4), e004342.”
- Strober, M., Freeman, R., Lampert, C., Diamond, J. S., Teplinsky, C., & DeAntonio, M. (2006). Are there gender differences in core symptoms, temperament, and short-term prospective outcome in anorexia nervosa? International Journal of Eating Disorders, 39(7), 570–575. https://doi.org/10.1002/eat.20293
- Strobel, C., Quadflieg, N., Naab, S., Voderholzer, U., & Fichter, M. M. (2019). Long‐term outcomes in treated males with anorexia nervosa and bulimia nervosa—A prospective, gender‐matched study. International Journal of Eating Disorders, 52(12), 1353–1364. https://doi.org/10.1002/eat.23151
- Smith, K. E., Mason, T. B., Murray, S. B., Griffiths, S., Leonard, R. C., Wetterneck, C. T., Smith, B. W., Farrell, N., Riemann, B. C., & Lavender, J. M. (2017). Male clinical norms and sex differences on the Eating Disorder Inventory (EDI) and Eating Disorder Examination Questionnaire (EDE-Q). International Journal of Eating Disorders, 50(7), 769–775. https://doi.org/10.1002/eat.22716