Unrecognized eating disorders in boys and young men

While the stereotype persists that eating disorders mainly affect women, a host of research from the past decade is now suggesting that these disorders—along with related mental health conditions such as body dysmorphia and subclinical disordered eating behaviors—don’t discriminate based on gender.

Boys and men now make up about a third of those diagnosed with an eating disorder (Mitchison, D., et al., Psychological Medicine, Vol. 50, No. 6, 2019opens in new window). Some boys and men experience more traditional eating disorders, such as anorexia nervosa and bulimia nervosa, with very traditional symptoms. However, others may experience disordered eating patterns outside an official diagnosis, such as body image disturbances, unhealthy weight or shape control behaviors, or loss of control over eating. Moreover, avoidant/restrictive food intake disorder, also known as ARFID, is a relatively new feeding and eating disorder category characterized by extreme food avoidance/restriction. A 2023 community-based study of more than 2,800 10-year-olds found approximately 6% of children experience ARFID, with no significant differences in prevalence between boys and girls (Sader, M., et al., JAACAP Open, Vol. 1, No. 2, 2023opens in new window).

Muscle dysmorphia, sometimes referred to as “bigorexia,” is characterized by excessive and compulsive exercise/weight training, a belief that one is insufficiently muscular, and an obsession with muscle mass, size, and leanness. It is more common in boys and men than girls and women, studies show. Several studies have also found muscle dysmorphia is becoming increasingly common in adolescent boysopens in new window. One study, published in the Journal of Adolescent Health, found by ages 16 to 25, a quarter of the 4,489 male participants told researchers they were worried about not having enough muscle. Eleven percent reported using muscle-building products such as creatine or anabolic steroids (Glazer, K. B., et al., Journal of Adolescent Health, Vol. 69, No. 4, 2021opens in new window).

“While overall, women do experience eating disorders at a higher rate than men do, I think people would be surprised by the number of men who do have eating disorders,” said Tiffany Brown, PhD, a psychology professor at Auburn University and codirector of the Auburn Eating Disorders Clinic, whose research focuses on developing and evaluating interventions for LGBTQ+ and male populations.

Men who struggle with these disorders face unique challenges, including stigma, misconceptions, and a reluctance to seek help. The differences in symptom presentation from the more widely recognized symptoms in girls and women often hinder timely diagnosis and treatment. And while awareness of male body image and eating disorder concerns has grown in recent years thanks to several celebrities sharing their struggles publiclyopens in new window, social media platforms may simultaneously be perpetuating the “ideal male” body image, adding to the complexity of the issue.

“We’ve always recognized that there is a subset of people, many of them boys and young men, who develop an unhealthy relationship with their bodies in the form of trying to become extremely muscular and doing so in a way that starts to really interfere with their lives,” said Lisa Damour, PhD, a clinical psychologist and author of The Emotional Lives of Teenagersopens in new window. “What I believe is happening now, and I’m eager for data to come along to help us get a clear look at this, is that social media and adolescent consumption of content around fitness, weight loss, [and] ‘getting cut’ is driving a larger population of boys and young men toward an unhealthy approach to their bodies.”

[Related: Boys and men with eating disorders aren’t getting the care they need]

What’s more, because the issue is still so underrecognized in boys and men, they are often more likely to face serious consequences. A study published in JAMA Open Network in December 2023 showed sharp increases in the rates of hospitalizations for boys with eating disorders (Smith, S., et al., JAMA Open Network, Vol. 6, No. 12opens in new window).

“If we’re not looking for something, then we’re really unlikely to diagnose it, and certainly bias and stigma come into play with any provider who is making a clinical diagnosis,” Brown said. “There was such a lack of awareness for a long time, and often men were more likely to be diagnosed with depression or something else versus an eating disorder because there has been this really inaccurate mindset that men don’t get eating disorders.”

Boys and men have also historically been excluded from research studies and the diagnostic criteria on eating disorders, experts note. It wasn’t until the release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, in May 2013, that the criterion of amenorrhea (loss of menstrual cycle) was removed from the diagnosis of anorexia nervosaopens in new window, allowing boys and men with the disorder to finally be able to receive an appropriate diagnosis.

Another element in the underrecognition of this issue in males is eating disorders have historically focused on the idea that the attitudinal, cognitive, and behavioral symptoms are driven by fear of weight gain and a pursuit of thinness, said Jason Lavender, PhD, a clinical psychologist by training and associate professor of medicine at the Uniformed Services University of the Health Sciences, in Bethesda, Maryland, who studies eating disorders and disordered eating among boys and men.

While some boys and men may pursue thinness, male body ideals are often focused more on muscularity or leanness (low body fat) rather than thinness or weight loss (lowering the number on the scale). As a result, they may display different types of unhealthy or maladaptive eating, weight control, and body shape control behaviors, such as excessive consumption of protein, compulsive exercising or weight lifting, or even the use of appearance/performance-enhancing substances including anabolic steroids and related synthetics.

“So, if [a clinician] is looking for just weight loss, which is the prototype of what we see in anorexia nervosa, then the behaviors that you see in boys or men who may have maladaptive symptoms may look different and may go underrecognized,” Lavender said.

Boys and men have also been left out of research on the best ways to measure and assess eating disorders, said Ross Sonnenblick, a psychology doctoral student at Drexel University in Philadelphia, whose research focuses on men’s experiences with eating disorders.

“As a result, those measures focus on symptoms that are more common in women, they use language that resonates with women, and they are insensitive to detecting eating disorders in men,” he said. To combat this, Sonnenblick’s dissertation work is focused on developing a screening tool designed to capture disordered eating symptoms in ways that are more relatable to men.

“This would include the more conventional symptoms, such as food restriction and purging, as well as ones that are more common in men, such as excessive exercise, excessive pursuit of weight lifting in an attempt to build muscle, and even anabolic steroid usage, which is especially prevalent among younger men and boys who might be trying to build muscle,” he said.

To make matters worse, disordered eating behaviors and overexercising, particularly in athletes, are often viewed as socially acceptable and are even encouraged as a sign of being “disciplined,” Brown said. This is true for girls and women as well, but it’s particularly common for parents, coaches, and other people in boys’ lives to reinforce these behaviors.

“Similar to how we’ve reinforced thinness for women, that can set off some dangerous behaviors in young men who are at risk for developing an eating disorder or muscle dysmorphia symptoms,” she said. It doesn’t help that over the past several decades, the idealized male body image has gotten bigger and bulkier. It’s an ideal that has even worked its way into toys and movies: Studies show that action figures have gotten more muscular since the 1970s (Baghurst, T., et al., Body Image, Vol. 3, No. 1, 2006opens in new window).

“These are literal superheroes that boys are looking up to, and they’re seeing this ideal in a man who’s there to help, and it ties a lot of those masculinity and muscularity things together,” Brown said.

Detecting eating disorders early is crucial for effective treatment. The signs may be subtle, and a child or teen need not meet all criteria for an eating disorder to benefit from intervention, Brown said. Simply being more aware that body image and eating concerns also occur in boys and men is an important part of the process, she noted.

This awareness needs to start happening as early as elementary school, said clinical psychologist Doug Bunnell, PhD, a clinical adviser for the Denver-based Eating Recovery Center and Pathlight Mood and Anxiety Center, an international center for eating disorders and mood, anxiety, and trauma-related disorders recovery.

“We need to do a way better job at making sure front-line primary-care providers, including pediatricians, nurses, school counselors, are thinking about eating disorders as a significant risk for kids, both boys and girls,” Bunnell said. He added that psychologists and counselors also need to be mindful of it with all their young patients.

“It’s often the case that a clinician will treat someone for anxiety or depression, and several years later the client tells them they have been binging, purging, starving, overexercising, using laxatives. It has to be something that we’re always asking about,” he said.

Potential warning signs of an eating disorder include an intense fear of weight gain; ongoing concerns with body weight and shape; unusual or rigid rituals, rules, or routines around food; inability or refusal to maintain a healthy weight; episodes of binge eating or purging; preoccupation with calories/macronutrients, eating, or body weight and shape; and excessive or strict exercise/weight-lifting routines.

Brown noted that while taking steps to eat more healthily and exercise more often are certainly positive and, on the surface, should not be cause for concern, if it gets to a point where it’s becoming excessive, it may be time for parents to start paying closer attention.

“If a teen starts to rigidly apply certain food or exercise routines, and it’s starting to impact their social functioning, their ability to go to school or class, or engage in coursework, those are things that would be the kinds of things to look out for,” she said.

When it comes to treatment interventions, Lavender noted that some men will do well in an eating disorder treatment developed largely in the context of this female-centric lens. But for others, they are likely to benefit from treatment that is better tailored to the unique considerations and factors that influence boys and men with eating disorders.

Bunnell agreed, adding that “there are things we can do to make treatment more accessible to men, more inviting to men, and to be careful not to just assume that things that your female patients were worried about are actually the words and concepts that he’s worried about.”

Rather than assuming a male patient is undereating to get thinner, boys and men may use terms such as “fitter,” “trimmer,” and “more defined,” Bunnell said, adding that he encourages younger practitioners or those who aren’t experienced in this area to start treatment by simply asking patients, “What does it feel like to be a boy these days?”

Prevention efforts in schools, within student athletic programs, and at home that focus on challenging cultural standards around what an “ideal man” looks like may also prove to be effective in reducing eating disorder and muscle dysmorphia risk factors in boys and men, suggests a pilot study led by Brown (International Journal of Eating Disorders, Vol. 50, No. 8, 2017opens in new window).

“It’s about having boys and men think about their own values and really try to challenge whether life would actually be that much better if they were to somehow achieve this lean, muscular body ideal. Probably not,” Brown said.