Current Findings on Males with Eating Disorders

Leigh Cohn, Raymond Lemberg, Leigh Cohn, Raymond Lemberg

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135046545
• Edition: 1
• Topic: Psicología
• Subtopic: Psicología clínica

The subgroup of males with eating disorders has been understudied, and this book presents the most comprehensive look at this topic since Arnold Andersen edited the text Males with Eating Disorders in 1990. This monograph represents both original research and reviews of other studies based on a special issue of Eating Disorders: The Journal of Treatment and Prevention, with additional added chapters. Representing international contributions from researchers and clinicians in nine countries, this cross-section includes chapters on etiology, sociocultural and gender issues, symptom presentation, assessment, medical and psychological concerns, treatment, recovery, and prevention.

1

A BRIEF HISTORY OF EATING DISORDERS IN MALES

Arnold Andersen

“Let me have men about me that are fat. Sleek-headed men and such as sleep at night. Yond Cassius has a lean and hungry look; He thinks too much.”

(Shakespeare: Julius Caesar, Act I, Scene 2)

This volume marks a milestone in the publication of new information concerning males with eating disorders, an all too infrequent occurrence in a history littered by neglect. There are multiple reasons for interest in males with eating disorders, because these problems: (1) are serious and potentially life threatening; (2) are frequently overlooked, trivialized, or dismissed for somewhat enigmatic reasons; (3) raise intellectually intriguing scientific, sociocultural, and historical questions; (4) present clinicians with challenges in identification and treatment; (5) illustrate trends in social and medical bias over the centuries; (6) appear to be increasing substantially in onset and prevalence; and, (7) raise issues of spirituality and what constitutes a peaceable relationship to the factual and imagined body in which we live and move.

Gender issues have been intriguing us since the story of Adam and Eve. Along other lines of narrative, evolutionary evidence has been tracing first the split of evolving species of increasing complexity into genders, while some more recent evidence has been teasingly interpreted as indicating males may be becoming less and less necessary for the future of the human race. At a minimum, the Y chromosome has changed and condensed. This chapter seeks to trace more recent and macro-level issues of definition, historical development, and clinical understanding.

What Are Eating Disorders, And What Does Their History Teach Us?

Eating disorders are present when clinical abnormalities co-occur, in three basic areas, whether quantitatively or qualitatively assessed:

1Behavior: abnormal eating behavior, and frequently, abnormal behaviors in exercise, fluid ingestion, substance abuse, or other patterns driven by the requisite psychopathology.

2Belief: an overvaluation of the need for and benefits of slimness and/or a specific body shape. The most common overvalued beliefs are: a relentless drive for thinness, a morbid fear of fat, and a persistent quest for lean muscularity.

3Body: physical abnormalities, not necessarily linked to reproductive endocrinology, resulting from the behaviors driven by the overvalued beliefs.

Some comment is required at this point regarding the diagnosis of eating disorders and the psychopathology of overvalued beliefs:

Diagnosis

Research demands and classification related to reimbursement in societies not providing universal health care often conflict with clinical reality. A patient with asthma may be virtually incapacitated or may have an occasional bout. Mild and intermittent forms of asthma are typically deemed worthy of clinical attention and reimbursement.

Not so with eating disorders. While the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association as well as the ICD-10 have brought a measure of standardization, they have also brought a draconian and changing pseudo-standardization in some areas of psychiatry, especially eating disorders. Double-blind, placebo controlled studies are valued where rationally needed, but are not required, for example, when a severed artery needs to be staunched. When a person suffers in mind, body, or social functioning because of abnormal eating, exercise, or other related behaviors, an eating disorder is present and deserves recognition and treatment.

DSM has a longstanding gender bias in regard to diagnosing eating disorders, especially anorexia nervosa, in males. The requirement for amenorrhea is obviously impossible for males, but has been present for at least two decades after studies showed the criterion to be irrelevant. Clinically, it was irrelevant since l689 when Morton described a male with anorexia! Lastly, the endless debate for what BMI or percent of age and height measures is required for diagnosis of anorexia nervosa is both fruitless and misleading. Weight, like height, is a bell-shaped curve. A weight reduction in a normal functioning individual who happens to be 20 percent above a chosen norm who then loses 20 percent may have all the hallmarks of anorexia nervosa that are recognized by an experienced clinician but meet none of the trade-marked criteria of DSM or ICD.

Overvalued Beliefs

Overvalued beliefs have become an orphan in the teaching of psycho-pathology in the United States, although not so much in Her Majesty's realms. Where has the psychopathology of overvalued beliefs gone? It has been largely airbrushed out of the picture. Kraepelin, Wernicke, and other distinguished students of psychopathology had no problem identifying patients as suffering from overvalued beliefs. Overvalued beliefs are present in a person's psyche when:

1The belief is a widely occurring sociocultural belief, for example, that it is good to take off weight.

2The belief has to have a ruling passion in an individual's life, hence the frequent occurrence of overvalued beliefs during adolescence, such as in the service of an eating disorder.

3The belief leads to dangerous or risky behaviors.

An eating disorder (with the possible exception of the very young), does not occur unless an overvalued belief is present. In truth, even a 7-year-old is often capable of saying, “I'm afraid of getting fat; I need to lose weight.”

Brief History of Eating Disorders in Males

Whether early Greek and Christian ascetics suffered from anorexia nervosa is not subject to any conclusive answer. Most early Western history was written about nobility—secular or religious—with few records of ordinary persons and their psychiatric or behavioral suffering. It is generally recognized that Richard Morton, writing first in Latin and then in English around 1690, described a woman and a man each suffering from what we would call anorexia nervosa. He not only excluded common medical causes of weight loss, but described the abnormal psychological state. A cluster of individual case descriptions were reported in the next two centuries. The modern era of describing anorexia nervosa may well have begun with the case series of Sir William Gull in the 1860s. He noted that the illness may occur in males, but gave few details. A few years later, Ernest-Charles Lasgue in Paris brilliantly described the family dynamics of patients with anorexia nervosa.

Males were then banished from existence for the next 100 years largely for two reasons. Anorexia nervosa was considered (for some decades) as a form of post-partum pituitary necrosis, and thereafter described in medical textbooks in the sections on endocrinology. Men obviously cannot suffer from post-partum disorders. More subtly misleading has been the association of anorexia nervosa with amenorrhea. For centuries, young women, their mothers, and physicians, have noted in diaries and clinical notes when a woman loses her “monthly courses.” Males have no such obvious indicator when they lose significant weight. Even though amenorrhea is present in only a subset of women with anorexia nervosa, it was one obvious medical sign physicians could describe. The continued emphasis on abnormal reproductive hormone functioning misleads clinicians to overlook other common medical sequelae of severe weight loss.

Males were next excluded from clinical recognition during the hegemony of psychoanalytic dominance, lasting until the 1960s. The common requirement for a diagnosis of anorexia nervosa was the finding in psychotherapy of the dynamic of “a fear of oral impregnation,” suggesting that anorexia nervosa concerned a confusion between orality and sexuality. Males obviously could not suffer from this dynamic theme.

It was only in the 1960s that clinicians at St. George's Hospital, in London, especially Arthur Crisp and colleagues, began empirical studies that included males with eating disorders. Research and clinical studies have been sporadic since then in other places, with males often being excluded from studies as a statistical nuisance because of their assumed rarity. Until recently, many medical studies have been recognized as flawed because of their exclusion of females. The opposite flaw has been repeated in the large majority of studies on eating disorders by excluding males.

When did the assumptions about the rarity of eating disorders in males begin to be questioned? There is no specific date, but in the late 1980s and especially the 1990s, the media placed greater and greater visual emphasis on males with a lean, muscular, chiseled body appearance. Males no longer could afford to be seen with a potbelly. Locker-room discussions increasingly were dominated by comparisons of how low a body fat could be achieved. The media and the social response have played an interactive role. There is no question that body norms have changed dramatically since the 1950s and 1960s. Today, the norm for a suit is at least an eight-inch drop between chest and waist, preferably greater, the “athletic” build. Action figures have become examples of increasingly impossible body muscularity—massive chests, narrow waists, and slim hips with thighs like tree trunks. The impression of increased eating disorders and related syndromes in males has been reinforced by epidemiological studies, especially the studies by Woodside and colleagues, that found in the general population a ratio of females to males that was between 2:1 and 3:1.

The whole field of eating disorders has been dramatically expanded by the definition of bulimia nervosa by Gerald Russell in 1979, and by the growing recognition starting in the 1990s by various groups of binge eating disorder. Ironically, the least common eating disorder, anorexia nervosa, has the longest historical record, albeit one that appeared and disappeared like Russian leaders airbrushed into and out of photos. Approximately 40 percent of patients with eating disorders are males.

Differences and Observations

The world of researchers in the field of eating disorders may be divided into “lumpers” and “splitters,” those that glom together males and females vs. those who appreciate the distinctions. Certainly many features of origin and clinical course—and even treatment—of males overlap with females, but the differences are crucial. To appreciate how great the disparity, one needs only to speak with a few families in which a male suffers from an eating disorder, but has been misdiagnosed, teased, or excluded from a treatment facility.

A few comments on differences between males and females may be useful here. First, consider the genders’ idealized body. I have not met a woman with an eating disorder who would accept a body weight 20 percent above average if she could specify a chosen body shape. Such a desire is not uncommon in males, especially if they could have a body fat below 4 percent and well-defined muscles all over, especially with an impressive upper body. Women tend to emphasize change below the waist, but men are more concerned with their waist and above. While many males with anorexia wish for an unhealthy degree of thinness, there are other preferred body types, which are less common in females. Beside the thin, gaunt look, many males desire a body type typical of today's Hollywood actors: normal weight and lean, shirtless muscularity. On the far end of the spectrum is a subgroup of eating disordered males, given the term “reverse anorexia nervosa,” (a somewhat clumsy, but useful subcategory) who never see themselves as adequately muscular or large enough. They often work out relentlessly not to become thinner, but larger, more muscular, and with no visible body fat. Anabolic steroids are often employed to further their overvalued belief in the necessity of bigness and muscularity.

Our society moves faster and faster, with more public visualization of the body, and especially of the body with minimal clothing. Therefore, whether in dating, advertising, in business advancement, or other areas, the first look may be the only look. Men are more driven than ever to conform to relatively new social ideals, which puts them at increased risk of developing eating disorders and body image dissatisfaction.

Questions with significant implications for health in males challenge us. The quest for a gene or genes related to the development of an eating disorder may be elusive. Certainly, in one sense, genes underlie everything, but such generalities are not of great practical use. Even where a specific gene is known, such as in Huntington's Chorea, all the metabolic steps from the gene to the illness remain largely unidentified. As a former bench researcher, this is written with empathy, not criticism. A huge gap is present in the bridge between basic science knowledge of males and the clinical condition of eating disorders. More clinical studies are needed, including those with matched males and females of each age, ethnicity, and social class. It comes close to a social taboo in scientific meetings to suggest that no medication may ever be found to be essential for most patients with eating disorders, but that may be the case and is certainly true today.

The core of eating disorders includes a profoundly spiritual element, as well as psychological and biological factors. Spiritual factors do not necessarily imply any religious traditions, but rather ask the question: When otherwise healthy males become morbidly dissatisfied with their body are they somehow rejecting a crucial part of their humanness? In this time of evolving gender roles, many men struggle with identity and meaning; and some fixate on their bodies rather than their less tangible inner being.

While a cluster of males have later onset for a variety of reasons, most males develop an eating disorder during their teens and early twenties. Our proactive goal should be to help growing boys and young men to internalize a healthy self-esteem and deep respect for their body type. They need to learn to emphasize their strengths, without comparing themselves to rampant images of impossible body sizes and shapes. Eating disorders are unfortunately a temporarily successful (albeit costly) way of achieving an identity that bypasses the messiness of healthy development. Parents must teach vulnerable boys to withstand the impossible body ideals advanced by media and their social contemporaries. Our challenge is to increase information about just which boys are most vulnerable so preventive intervention can be made specific.

This volume offers new and important information about males with eating disorders by a diversity of authors from the international community. These are international disorders and this field requires international studies, including translations of standards tests and sharing of results. While eating disorders remain enigmatic in many ways, enough is known about their identification and treatment ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• About the Editors
• About the Contributors
• Acknowledgments
• Introduction
• 1 A Brief History of Eating Disorders in Males
• Part I Etiology (Sociocultural and Gender Issues)
• Part II Assessment
• Part III Medical and Psychological
• Part IV Treatment
• Part V Recovery and Prevention