How Eating Disorders Develop in Boys & Men

Eating disorders affect men and boys at nearly the same rate as women, yet they often go undiagnosed due to stigma and misconceptions. Males may develop eating disorders driven by muscularity desires, body dissatisfaction or pressure from sports, social media and peer expectations. This can lead to severe health complications including low testosterone, osteoporosis, infertility and cardiovascular issues. Early intervention, medical stabilization and specialized treatment approaches are shown to be most effective for recovery. By understanding the impact of eating disorders on males, we can improve recognition, treatment outcomes and overall mental and physical health.

Can Men Have Eating Disorders?

Eating disorders are often seen as a female illness, but more men and boys are receiving treatment than ever before. From 1999 to 2009, hospitalization of males for eating disorders increased by 53%.¹ Despite misconceptions about eating disorders and gender, the truth is that anyone of any gender or sex can suffer from an eating disorder.

Eating disorders in men are often overlooked and go undiagnosed, despite how many men and boys struggle with body image issues. It’s commonly stated that only 10% of people with eating disorders are men, but this statistic only reflects presentations at clinics and hospitals and underestimates the true prevalence among men and boys.² Population-based studies suggest that the prevalence of eating disorders is nearly equal between men and women.²

Presentation of Eating Disorders in Men & Boys

While both men and women can experience eating disorders, their symptoms often differ. Men are usually motivated by a desire for muscularity rather than the thinness typically sought by women.

However, men experience all disordered eating behaviors, including:³

• Food restriction (96%)
• Overexercising (40%)
• Purging, including laxative abuse (23%)
• Binging (15%)

Age of onset

Males with eating disorders typically fall into three age categories:²

• Child onset before 12
• Preteen through early twenties
• Young men and mature adults

The issues that lead to dieting and disordered eating in these populations vary widely. Very young boys often face problems at home, such as family conflict, moving, or changes in the family dynamic, while adolescent males struggle with questions of identity and aim to improve aspects of their lives like relationships, sports performance, military enlistment or preventing weight-related illnesses.²

While eating disorders are found across all ages, most in males develop during the teenage years or early twenties. However, dissatisfaction with body image can start as early as six years old, with 32% of six-year-old boys wanting to be more muscular and 20% wishing to be thinner.⁴

Eating Disorders in Men

Muscularity-driven eating disorder

Muscularity-driven eating disorder (MDED) is common among men. MDED describes abnormal eating habits and excessive exercise aimed at gaining more muscle and stems from the fear of being too small.² While MDED is not a formal diagnosis, it can be a helpful term for men to describe their experiences.

Over the past twenty years, many studies have examined the drive for muscularity among males dissatisfied with their body image. In a survey of young adults, 22% of males and 5% of females reported engaging in muscularity-focused disordered eating behaviors.⁵ Men are much more likely to desire increased muscularity than women and do not necessarily oppose weight gain. Men are more concerned with shape than weight, and weight might even be welcomed if it is linked to increased muscle mass, more definition, or lower body fat.

Anorexia nervosa in men

It’s estimated that 20% of people with anorexia nervosa are male.⁶ The presentation of anorexia nervosa is similar in both men and women, but men often have different motivations. Women restrict their food intake mainly to attain the thin ideal, while men may restrict to achieve thinness or to become leaner but still toned, also known as “cutting (weight).”

Bulimia nervosa in men

Among men with eating disorders, an estimated 30% are thought to have bulimia nervosa.⁶ Some studies suggest that men with bulimia experience less concern about eating and do not have as much loss of control during binge episodes.

Some experts point out that a binge episode is more likely to occur as a “cheat meal” – a planned high-calorie meal that can reach up to 9,000 calories, usually within a strict diet or fitness routine.

Binge eating disorder in men

Binge eating disorder (BED) is the most common diagnosis among eating disorders, with 43% of individuals with BED being men and boys.⁶ Studies also indicate that men are three times more likely to report a clinically significant frequency of binge eating compared to women.

Other eating disorders in men

Men and boys comprise the majority of individuals diagnosed with some other eating disorders, including up to 77% of those with other specified feeding or eating disorder (OSFED) and 67% of those with avoidant restrictive food intake disorder (ARFID).^6,7

Self-perception & Body Image in Men

Male body ideals

Men and boys experience a broader range of body ideals than women and girls. While females often desire only thinness, males aim for various physique goals, including very thin, extremely muscular and lean muscularity.²

From a young age, the media displays images of impossibly fit men with defined abs and lean muscularity as the male ideal, which is the most desired body type among men.² Men and women also tend to focus on different areas of the body. While women tend to be dissatisfied with their bodies from the waist down, men tend to be dissatisfied from the waist up.²

Perception of weight

Unlike girls, boys tend to perceive themselves as overweight only when they are slightly above average.² This is also when adolescent males are most likely to develop their eating disorder. Because there is less pressure on boys to diet compared to girls, they usually do so only under certain conditions:²

• To avoid being teased about being a higher weight like in their childhood
• To increase sports performance
• To 2developing similar weight-related medical illness as their father
• To attract men, if gay or bisexual

Risk Factors for Eating Disorders in Males

Gay & bisexual orientation

Research indicates that up to 42% of males with eating disorders are gay or bisexual.⁸ For these men, a higher BMI, peer pressure, gender role conflict, and lower levels of masculinity are linked to greater body dissatisfaction and disordered eating behaviors.⁹ Gay and bisexual boys also face higher rates of:

• Disordered eating behaviors
• Body dissatisfaction
• Purging
• Binge eating
• Diet pill usage
• Fasting

Social media and dating app use have been linked to the development of eating disorders in gay and bisexual men. The pressure to achieve a particular body type to attract a partner and the emphasis on physical appearance on dating apps and social media can intensify body image issues.⁹

Sports, hobbies & work

Males who engage in sports, hobbies or careers that promote thinness for appearance and/or performance are more likely to develop disordered eating behaviors than their peers.

Sports are a well-researched risk factor for developing an eating disorder, with 19% of male athletes experiencing disordered eating behaviors and 8% having been previously diagnosed with an eating disorder.¹⁰

It can be more difficult to identify and diagnose due to stigma or concerns that their athletic season will be affected by treatment. Elevated rates of eating disorders are found in many sports, including:

• Wrestling
• Gymnastics
• Swimming
• Track and field
• Equestrian
• Football

Certain jobs that focus on looks also have a higher risk of eating disorders, such as modeling and dancing.

How Does Stigmatization Affect Men with Eating Disorders?

Males with eating disorders are often stigmatized because of their condition. There is a concern and shame among patients that they will appear less masculine for struggling with an eating disorder, which may cause men to delay seeking treatment, which can be dangerous. "A delayed diagnosis can make medical complications more severe and put patients at risk of developing a variety of severe medical complications that require medical stabilization," explains Allison Nitsch, MD, FACP, CEDS, Physician Team Lead at ACUTE.

Additionally, some health professionals are uneducated about eating disorders in men and boys and may not recognize symptoms in males or hesitate to diagnose males with an eating disorder. Some programs do not accept male patients, further stigmatizing eating disorders in men and boys.

Medical Complications of Eating Disorders in Males

Low testosterone

Eating disorders in males can disrupt the male gonadal axis.² Diminished luteinizing hormone (LH) fails to stimulate Leydig cells in the testes to produce testosterone, leading to low testosterone levels, decreased sex drive, and reduced sexual function. Low testosterone can cause fatigue, decreased muscle mass and reduced bone density.

Gynecomastia

Low testosterone and other hormonal imbalances can lead to gynecomastia, a condition where the male breast tissue becomes enlarged.¹¹ This can cause emotional distress and low self-esteem in patients, which may reinforce disordered eating behaviors in an attempt to fix it.

Infertility

Low testosterone and malnutrition can reduce sperm count and quality, potentially causing fertility problems during an active eating disorder.

Osteopenia & osteoporosis

Many providers may not consider osteoporosis in male patients because lower bone mineral density is associated with women. However, males with eating disorders who are underweight for at least six months experience osteoporosis more often than their female counterparts.¹² Contributing factors for osteoporosis in men may include:

• Low testosterone
• Diminished calcium intake
• Low body weight
• Elevated cortisol

Cardiovascular complications

Malnutrition and electrolyte imbalances put individuals with eating disorders at an increased risk of cardiovascular complications, including bradycardia and hypotension. Patients with bulimia nervosa are at an increased risk of coronary heart disease (CHD). This risk may be compounded in men, who are already at a greater risk of developing CHD than women.¹³

Muscle weakness & atrophy

Men with eating disorders may suffer from muscle weakness and atrophy caused by insufficient nutrient intake and overexercising.

Mental health issues

Men with eating disorders are at a higher risk of developing other mental health issues than their peers. They are also more likely to experience depression, anxiety and substance use abuse.^14,15

Eating Disorder Treatment for Men

Medical stabilization for men with eating disorders

Medical stabilization is generally similar between men and women, except for a few conditions that uniquely affect men.

Nutritional rehabilitation for men

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.²

Additionally, weight gain can be supported through liquid supplementation in the early stages of refeeding. Important vitamins and minerals like calcium and vitamin D can also be supplemented.

Refeeding syndrome prevention

Patients experiencing severe eating disorders or malnutrition are at an increased risk of developing refeeding syndrome during their nutritional rehabilitation and weight restoration. It's of critical importance to monitor lab values for refeeding syndrome, like phosphorus, potassium and magnesium.

Physical therapy

Alongside weight restoration and nutrition therapy, physical therapy should be used to treat men with eating disorders who are at risk for osteoporosis and osteopenia, alongside restoring testosterone levels and replenishing key vitamins and minerals.

Once at a restored weight, moderate exercise with low-impact weight-bearing activities exerts force on the bones, which can help encourage bone growth. Resistance training is especially valuable because it improves morale, fosters a sense of contribution to goals, increases lean muscle mass, and reduces abdominal fat deposits, leading to better remission. It also provides a healthy environment for men to work out together.

Testosterone supplementation

Testosterone supplementation is an optional approach to treat low testosterone in men with eating disorders. However, it remains unclear whether testosterone replacement or a natural return to normal levels is more beneficial.

Because of the risk of premature closure of the bony growth plate, extreme caution should be taken when considering testosterone replacement in males who are not close to full height or maximum bone growth.²

Psychological Interventions for Men with Eating Disorders

Male group therapy

Men may benefit more from mixed-gender or male-only group therapy options. In groups that are mostly female, the presence of male patients can be seen as threatening or disruptive to what is considered a safe space for women. They may also be viewed as substitutes for an abuser. These factors can create an unproductive or hostile environment for males with eating disorders.

Male-only groups also offer the advantage of reducing stigma or perceptions of males being atypical, enabling men to share their experiences, discuss cultural messages about the ideal male body, and build connections with other men.

Addressing eating disorder stigma

Men with eating disorders often face societal stigma because these disorders are frequently and inaccurately seen as affecting only women. Therapists and healthcare providers should be mindful of this and work with male patients to address these issues.

Incorporating male body image concerns

Men often face unique societal pressures related to body image, emphasizing musculature and leanness. Treatment for men frequently needs to focus on these specific concerns instead of defaulting to the female experience, which is common in many eating disorder programs.

Treating co-occurring psychiatric conditions

Men with eating disorders are more likely to have co-occurring psychiatric conditions, such as substance use disorders. This should also be addressed by a multidisciplinary treatment team.

Treatment Outcomes for Males with Eating Disorders

Males and females respond similarly to treatment, with findings indicating that men have comparable or better treatment outcomes than women.¹⁶ Men also experience a similar remission rate for anorexia nervosa, but a slightly lower remission rate for bulimia nervosa.¹⁷

Getting Help for a Severe Eating Disorder

Men with eating disorders may find it hard to seek help due to stigma. But with the evidence-based care, full recovery is possible. An eating disorder affects both physical and mental health, sometimes without clear warning signs. Medical support and nutrition therapy are essential to help restore your health.

Start now with a free assessment.

References

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