Eating Disorders In Men

In 1994, newly ensconced in London, hundreds of miles from his native Edinburgh and struggling with the difficulties of a Ph.D. program in biochemistry, Ian C. Boulton felt his life spinning out of control. To restore order, he decided to focus on his health. He began running and swimming, watching what he ate, and working to get his body into really terrific shape.

Unfortunately, those very efforts to gain control themselves soon spun out of control. Within a year, Boulton was vigorously exercising an hour or more a day, and eating less than one-third the calories needed to sustain his 6-foot-1-inch frame. By the time he visited his parents back in Scotland the following year, he’d lost more than 50 pounds, some 30 percent of his body weight.

Only then did the magnitude of what he’d become sink in.

For during that visit, while swimming with his father, Boulton noticed the older man off to himself by the side of the pool. When Boulton swam over, he found his normally stoic father weeping. “Because he could see every rib, every vertebrae,” Boulton recalls. “He could see that my knees were thicker than my thighs, and that I could barely hold up my head.”

He could see that his son was dying.

Numbers Increasing Dramatically

Like an estimated 1 million men in the United States, Boulton was suffering from an eating disorder; in his case, anorexia nervosa. While numbers are difficult to come by, estimates are that at least 5 percent to 10 percent of those with one of the three identified eating disorders — anorexia, bulimia and binge eating disorder — are male. And, experts agree, in the past decade, the number of males with eating disorders and other body-image disorders has increased dramatically. Perhaps even more alarming is the story the numbers don’t tell. One estimate has it that while one in 15 patients with an eating disorder is male, in the community at large one in six people with an eating disorder is male.

“This suggests that many more men are suffering with these problems than we know,” says Roberto Olivardia, Ph.D., a clinical fellow at Harvard Medical School and co-author of “The Adonis Complex: The Secret Crisis of Male Body ” (2000: The Free Press), “because they do not seek treatment.”

Olivardia and his co-authors, Harvard Medical School professor of psychiatry Harrison G. Pope, Jr., M.D., and Brown University associate professor of psychiatry Katharine A. Phillips, M.D., coined the term “Adonis complex” to represent a continuum of body-image disorders in men, including eating disorders, muscle dysmorphia (in which men who are very muscular still see themselves as scrawny and small), and body dysmorphic disorder (in which a man believes that a certain part of his body, like the nose, penis or skin, is very ugly and defective).

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Says Olivardia: “We see a lot of men today trying to pursue a perfect body.”

The reasons for the increasing numbers vary, Olivardia says, but perhaps the primary reason is the growing prevalence of male images in the media.

“Certainly the images that boys are confronted with today are much more aggressive in dictating to them that there is an ideal body for boys, much like girls have always had this historic bombardment saying they need to be thin,” he says.

Just consider:

  • Between 1999 and 2000, there was a 23-percent increase in the number of cosmetic-surgery procedures performed on men.
  • The use of steroids, creatine and other muscle-building supplements is epidemic among teen-age boys.
  • The number of magazines targeted toward men that focus on bodybuilding and health, often depicting the glistening and pumped-up naked chests of men, have proliferated in the past decade. A new magazine, MH18, was launched to appeal to boys ages 14 to 18.
  • Men’s bodies are used to sell everything these days from tampons to coffee liqueur.

And just as the centerfolds of women in Playboy magazine have depicted ever-thinner women over the years, the centerfolds of men in Playgirl magazine have depicted men with less body fat and more muscles, according to an analysis Olivardia and his cohorts conducted.

Even that plastic male doll, GI Joe, has gotten more buff. If he were a real man, Olivardia says, at 5 feet 10 inches he’d have 29-inch biceps, a 32-inch waist and a 55-inch chest. “He’d be the biggest bodybuilder of all time.”

The images and messages even pop up in video games. In the game Duke Nukem, for instance, if the proponent loses his energy he can click on the hidden bottle of steroids to get more muscular. “This is a game marketed towards 10- to 15-year-old boys,” Olivardia says. “By the time they hit adolescence, they have totally internalized this image that this is what they need to look like to be accepted.”

Boulton wasn’t aware of the influences media images played on his own illness when he was sick, he says. “It’s a bit like a fish trying to discover water — you’re not aware of it because you’re immersed in it.” Today, Boulton is a research fellow at the University of Toronto, and through his work with various groups, including for the National Eating Disorders Information Center in Toronto, he helps to publicize the effects that media messages can have on body image and, ultimately, on personal well-being.

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“The images we have are all images of perfection,” he says. “Thin perfection. And it’s all lies. The association between advertising and body dysmorphia is almost indisputable,” he says.

But in a world in which college dormitories post signs warning women — not men — to clean up after vomiting, and in which parents of teen-age girls are hypervigilant about signs of eating disorders in their daughters but think nothing of their sons “dropping 10” in a weekend to make weight for a wrestling match, the idea that men might also suffer from these disorders is still somewhat foreign.

When Boulton finally admitted to himself he had a problem and sought help, one doctor told him men didn’t get anorexia. Instead, the physician prescribed “three fried meals a day,” Boulton says. “This, when I could barely eat an entire apple without having a panic attack.”

This identification of body image and eating disorders with females also makes it harder for men to admit they need help, says David B. Herzog, M.D., professor of psychiatry at Harvard Medical School. “And, because the primary-care physicians don’t have eating disorders on their diagnostic screen when they’re evaluating males, they’re not asking the same questions they might ask of females,” he says, questions that would help pinpoint a problem.

It’s particularly ironic, since the case of an anorexic male was one of the first published case histories in medical literature more than 300 years ago.

The diseases are very similar in both men and women, Dr. Herzog says, and just as dangerous, with potential consequences ranging from heart disease, to cancer of the esophagus (from induced vomiting), to pancreatitis, heart disease and death.

While the rates of men with full-fledged anorexia and bulimia are lower than those for women, the rates in both genders for binge eating are about the same. Olivardia recalls one patient who was so obsessed with food he would stand in a McDonald’s just to smell frying food.

Men also are usually far sicker by the time they seek help, Dr. Herzog says. He recalls a 17-year-old boy who had just completed the Boston Marathon. At 6-feet-2-inches, the boy weighed 120 pounds. “He said to me, ‘I don’t think I look any different than a lot of the other runners.'”

In fact, runners, along with weight lifters, have a higher-than-normal risk of developing eating disorders. The National Runner’s Survey on Dieting and Eating found that 21 percent of 2,640 men who responded said they were “terrified” of gaining weight either “often,” “usually” or “always.”

Ironically, a man can look fabulous — with huge muscles from hours spent in the gym — and still be suffering from an eating disorder, Olivardia notes. The typical case of muscle dysmorphia, he says, is a man who is very physically fit, weighs over 200 pounds, but whose percentage of body fat is extremely low — less than 8 percent. Male athletes generally have body-fat percentages ranging between 6 and 13 percent.

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“He’s very muscular, but he believes he’s very small,” Olivardia says. Some men are so ashamed of their bodies that they wear three or four layers of clothes and never take their shirts off in public. One patient refused to leave his house if he didn’t think he was in top physical shape. “I need to look perfect on the outside to make for everything that’s not on the inside,” Olivardia recalls him saying. “He said his soul was empty and dead.”

Treatment for these disorders typically involves some type of cognitive behavior therapy, in which the therapist challenges the patient’s beliefs about himself; or psychotherapy, to get at family issues that may be feeding the disorder. Often, Olivardia says, men with body-image disorders grew up in dysfunctional families, have a history of trauma, or had families in which there was little communication. “So food becomes a way of dealing with emotions like depression or loneliness,” he says.

Boulton says he couldn’t even begin to work on the underlying psychological issues connected with his anorexia until he put on at least 30 pounds. He was so malnourished, he said, that it had affected levels of certain mood-controlling hormones and neurotransmitters, and he was simply unable to think clearly enough to make psychological progress. He adds, “The immediate priority was physical recovery, and my therapist coaxed me toward this goal, offering support through the inevitable crises.”

It took two years of hard work, he says, before he finally considered himself healthy again. “One of the benefits of recovery is that you’ve seen your own death,” he says. “And that helps you establish a new perspective on life.”

Today, he laughs more, takes more risks, and suffers fools less patiently. Most important, he makes mistakes. “And that’s OK. Before, making mistakes wasn’t acceptable, so I ended up frozen, static and ultimately close to death.”

He feels a mission to tell others of his story so that more men who suffer as he suffered will realize they’re not alone.

“Exposing the mythology of beauty, the dubious value of thinness and, critically, the voracious profiteering which feeds on our collective search for “the ideal” is a cause I am committed to,” he says.

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