Approximately 1.25 million people in the UK have a diagnosed eating disorder (such as Anorexia and Bulimia Nervosa) with official statistics showing that men and boys make up 10% of these patients (Beat; Mental Elf). Until recently, the literature has been sparse when it has come to accounting for the male experience, with it being accepted that males are considerably less likely than their female counterparts to have an eating disorder.
Evidence is building however to highlight that more males are experiencing eating disorders, with rates of up to 25% of total patients in some studies (Hudson, Hiripi, Pope & Kessler, 2007). NHS figures released in November 2018 show that the prevalence of eating disorders in young men in hospital have increased by 98% between 2010 and 2018, growing at a faster rate for boys than girls (NHS Digital, 2018).
The discrepancies across prevalence figures reported in evidence and practice signify difficulties in understanding and managing this group, with men with eating disorders becoming “…underdiagnosed, undertreated, and misunderstood” (Strother, Lemberg & Tuberville, 2012). This is pretty interesting when you consider that in 1686 Anorexia Nervosa was first described in medical texts by Dr Richard Morton within a case study of a teenage boy.
There has been a growing level of attention within this area of research in the last decade to addressing these discrepancies, to help understand the male experience (Robinson, Mountford & Sperlinger, 2012; Räisänen & Hunt, 2014; Griffiths, Mond, Li, Gunatilake, Murray, Sheffield & Touyz, 2015), however there has been a historical oversight of men as participants within studies focused on the development of interventions and treatments. This has left us in a position of being unsure if these evidence-based approaches are actually evidence-based for men and boys.
Emerging research has examined outcomes in male samples and have shown that treatment modalities are likely to be equally valid when tested with male patients (Fairburn, Cooper & Shafran, 2008; Dakanalis, Timko, Clerici, Zanetti & Riva, 2014) and that being male is not an adverse factor in treatment outcomes (Fairburn, 2008). This is promising, but the continued focus on females and the limited validation carried out with male samples leaves many questions for clinicians who are treating boys and men in practice (this Mental Elf Blog gives a good insight into transforming interventions for men). The recent paper by Kinnaird, Norton and Tchanturia (2019) acknowledges this dilemma that clinicians face and aims to make sense of the needs of men receiving treatment for eating disorders.
The study was part of a service improvement project that used a qualitative design conducting a range of semi-structured interviews with clinician staff working within one eating disorder service within an inner city London, which reported 12% of patients in the service as male. Interestingly all of the clinical staff who participated in the study were female.
The aim of the interviews was to examine two research questions:
- Do men with eating disorders have gender-specific issues related to their illness?
- Do men with eating disorders need gender-specific treatment options?
The results are split into three main areas:
1. Male-specific issues
It was agreed by participants that for the most part, symptoms are the same across genders, with the exception of masculinity, which was felt by clinicians to link with difficulties engaging with the emotional aspect of treatment. This wasn’t a universally held belief by clinical staff, with some acknowledging that the “challenge” to engage with treatment and emotion was a general part of the illness.
2. Treatment approaches
Most clinicians didn’t feel that a gender-specific treatment was needed, but rather adaptions could be made to ensure treatment was individualistic (not gendered). The only aspect of treatment that it was felt may need to be tweaked for gender was psychoeducation to address stigma, alongside adaptions towards challenging masculinity (rather than female body image ideals around the thin ideal).
A promising finding was that most professionals felt confident to treat a male with eating disorders in their service, but this was linked to the experience and support in practice, not training showing that less experienced staff or other services outside of this one may see staff feeling less confident.
3. Creating a male-friendly environment
Participants instead felt that it was the environment not the treatment that needed addressing by this service improvement project. Aspects such as having gender neutral posters and literature in the waiting areas and treatment rooms had happened to make a more male-friendly environment in a service that is still female-dominated (exemplified by the all-female staff demographic). Participants acknowledged that these environmental aspects are likely to endorse and reinforce the stigma that eating disorders are an illness that only affects women and girls.
The paper reinforces our understanding that male eating disorders are not alien and new, complementing the literature that exists to tell us that the similarities outweigh the differences between genders (in the way that we view most physical illnesses as gender-neutral). Of course some aspects differ, but the findings suggest that clinicians view this as part of the individualist nature of the illness:
Although men do present with specific treatment needs, these can typically be met within the framework of typical treatment approaches by experienced clinicians in an environment sensitive to the presence of men in an otherwise female-dominated space. However, there are a lack of explicit guidelines for this process, and areas such as male-only treatment spaces require further research.
Strengths and limitations
A limitation to the paper is that we do not know how many clinicians took part in the project. While the authors cite 55% of the total number of staff in the service, we don’t have the core number so it is difficult to know how wide ranging such experiences are. Additional information about professional role or training received would be helpful to contextualise the paper.
A strength of the paper is that this review of clinicians understanding of male eating disorders, draws on a wealth of clinical experience within a service that has a history of best practice and treating men. This in itself is also a limitation however as we are only seeing the experiences of staff who are confident and experienced in the area. This is not the entire picture of services that men in the UK (and further afield) will experience, with previous research finding that healthcare providers report that they feel nervous assessing and treating such illnesses (Clarke & Polimeni-Walker, 2004; Hay, Darby & Mond, 2007). Poor knowledge of male eating disorders may, therefore, be attributed to the challenging experiences highlighted within men’s accounts of treatment seeking; including accounts of misdiagnosis, rejection of an eating disorder diagnosis and missing important symptoms or risk factors (Räisänen & Hunt, 2014).
Implications for practice
It seems that more men are developing eating disorders, so we should be grateful the great work of charities such as B-eat, First Steps, Eating Disorders Association NI and The Laurence Trust, which helps to raise awareness and means that more men are able to come forward and seek-help. Clearly, services need to be equipped to manage the 98% increase in admissions from males.
Overall, the paper points towards the need to create a male-friendly environment for improving eating disorder services.
What feels personally of impact for me is that the reinforcing that an eating disorder is an eating disorder, irrespective of gender, allows for a discussion and acceptance that we don’t need to focus on developing entirely new treatments but to provide treatment flexibly.
Core aspects related to difficultly engaging patients in treatment (such as emotion dysfunction) are universal for the illness and require treatment models to address them, rather than simply being attributed to gender (Foye, Hazlett & Irving, 2018). Moving the conversation in this direction can have a real impact on practice and seeing patients as people again, not as different or othered by their gender, age or presentation.
We have the evidence to show an eating disorder is an eating disorder, and reinforcing the differences only create stigma and fear. Summed up in the words of a male who has recovered from anorexia when asked what it feels like to be a man with an eating disorder…?
I don’t know, I’ve never been a woman with an eating disorder!
– Dave Chawner
Kinnaird E, Norton C, Tchanturia K. (2018) Clinicians’ views on treatment adaptations for men with eating disorders: a qualitative study BMJ Open 2018;8:e021934. doi: 10.1136/bmjopen-2018-021934
Clarke, D., & Polimeni-Walker, I. (2004). Treating individuals with eating disorders in family practice: A needs assessment. Eating Disorders, 12, 293–301.
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.
Fairburn, C.G. (2008). Eating Disorders: The Transdiagnostic View and the Cognitive Behavioural Theory. In Fairburn, C.G. (Ed), Cognitive Behavioural Therapy and Eating Disorders (pp. 7-22). New York: Guilford Press.
Fairburn, C.G., Cooper, Z., & Shafran, R. (2008). Enhanced cognitive behavior therapy for eating disorders (“CBT-E”): An overview. In: Fairburn, C.G., (Ed). Cognitive Behavior Therapy and Eating Disorders (pp. 23-34). Guilford Press; New York.
Foye, U, Hazlett, D.E. & Irving, P. (2018). ‘The body is a battleground for unwanted and unexpressed emotions’: exploring eating disorders and the role of emotional intelligence, Eating Disorders, DOI: 1080/10640266.2018.1517520
Griffiths, S., Mond, J.M., Li, Z., Gunatilake, S., Murray, S.B., Sheffield, J., & Touyz, S. (2015). Self-stigma of seeking treatment and being male predict an increased likelihood of having an undiagnosed eating disorder. International Journal of Eating Disorders. DOI: 10.1002/eat.22413
Hay, P., Darby, A., & Mond, J. (2007). Knowledge and Beliefs about Bulimia Nervosa and its Treatment: A Comparative Study of Three Disciplines, Journal of clinical psychology in medical settings, 14 (1), 59-68.
Hudson, J.L., Hiripi, E., Pope Jr., H.G., & Kessler, R.C. (2007). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348-358.
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: e004342. doi:10.1136/bmjopen-2013- 004342.
Robinson, K.J., Mountford, V.A., & Sperlinger, D.J. (2012). Being men with eating disorders: perspectives of male eating disorder service-users. Journal of Health Psychology, 18(2), 176-186. DOI: 10.1177/1359105312440298
Strother, E., Lemberg, R., Stanford, S.C., & Turberville, D. (2012). Eating disorders in men: underdiagnosed, undertreated, and misunderstood. Eating Disorders, 20(5), 346-355.