Eating Disorder - Relevance of Studies On Attentional Biases On The Treatment of Eating Disorders - in Men

In Men

To date, the evidence suggests that the gender bias of clinicians means that diagnosing either bulimia or anorexia in men is less likely despite identical behavior. Men are more likely to be diagnosed as suffering depression with associated appetite changes than receive a primary diagnosis of an eating disorder. Using examples from a Canadian context below, it is possible to engage with some of the more nuanced issues facing men suffering from disordered eating.

There are many societal, familial and individual factors that can influence the development of an eating disorder. Individuals who are struggling with their identity and self-image can be at risk, as well as those who have experienced a traumatic event (A Report on Mental Illness in Canada, 2002). In addition, many sufferers of eating disorders report feeling powerless about their socioeconomic environment, and view dieting, exercise and purging as empowering means of controlling their lives. The conventional approach (Trebay, 2008 and Derenne & Beresin, 2006) to understanding the root causes of disordered eating focuses on the role of media and sociocultural pressures; an emphasis on thinness (for women) and muscularity (for men) often goes beyond simple body image. There is an implicit media message that not only are those with ‘ideal’ bodies can be more confident, successful, healthy and happy but that slimness is associated with positive character qualities, such as reliability, trustworthiness and honesty (Harvey & Robinson, 2003).The traditional understanding of eating disorders reflects a media construct where thin and attractive people are not only the most successful and desirable members of the community, but rather they are the only members of the community who can be attractive and desirable.

In such a view, society is focused on appearance; body image becomes central to young people’s feelings of self-esteem and self-worth — overshadowing qualities and achievements in other aspects of their lives (Maine & Bunnell, 2008). Teenagers may associate success or acceptance by their peers with achieving the ‘perfect’ physical standard portrayed by the media. As a result, during the period where children and teenagers become increasingly more exposed to prevailing cultural norms, both males and females are at risk of developing skewed conceptions of self and their bodies (Andersen & Homan, 1997). When the desired goals are not met of achieving the ideal body image, they might experience feelings of failure that contribute to further drop in self-esteem, confidence and an increase in body image dissatisfaction. Some also suffer psychological and physical costs such as feelings of shame, failure, deprivation and yo-yo dieting (Maine & Bunnell, 2008). Eating disorders may cause individuals to feel tired and depressed, decreased mental functioning and concentration, and can lead to malnutrition with risk to bone health, physical growth, and brain development. There are also increased risks of osteoporosis and fertility problems, weakened immune system, heart rate, blood pressure and metabolic rate is also decreased (NEDIC, 2006). Additionally, sufferers from eating disorders show the third highest susceptibility for self-abuse and suicide, with rates 13.6 and 9.8 times higher than the Canadian average, respectively (Löwe et al., 2001).

Until recently, eating disorders have been characterized as an almost exclusively female problem (Maine and Bunnell 2008). The majority of early academic scholarship during the early 1990s tended to dismiss the prevalence in men as largely, if not entirely, irrelevant when compared to that in women (Weltzin et al. 2005.). Only recently have sociologists and feminist thinkers expanded the scope of eating disorders to identify with the unique challenges facing male sufferers.

Eating disorders are the third most common chronic illness in adolescent boys (NEDIC, 2006). Using currently available data, it is estimated that 3% of men will be affected by eating disorders in their lifetime (Public Health Agency of Canada, 2002). Eating disorder rates are not only increasing among females but also males are more concerned with their body image than ever before. The Public Health Agency of Canada (2002) found that almost one in every two girls and almost one in every five boys of grade 10 either were on a diet or wanted to lose weight. Since 1987, hospitalizations for eating disorders in general hospitals have increased by 34% among young men under the age of 15 and by 29% among men between 15–24 years old (Public Health Agency of Canada, 2002). Across Canada, age-standardized hospital separation rates for eating disorders were highest among men in British Columbia (15.9 per 100,000) and New Brunswick (15.1 per 100,000) and lowest in Saskatchewan (8.6) and Alberta (8.6 per 100,000) (Public Health Agency of Canada, 2002).

Part of the challenge with addressing the prevalence of eating disorders in men is a lack of research and statistics that are both current and appropriate. Recent work, such as that by Schoen and Greenberg (Greenberg & Schoen, 2008) suggests that the same prevailing social factors which led to a rise in eating disorders amongst women in the late 1980s may have also clouded public perceptions of similar male vulnerabilities. As a result, male eating disorders and prevalence have been underreported and misdiagnosed. Specifically, attention has recently been drawn to the gendered nature of diagnosis and dissimilar methods of presentation in men; diagnostic criteria focusing on weight loss, fear of fat and physical symptoms such as amenorrhea are cannot be applied to male sufferers, many of whom exercise excessively, are concerned with muscularity and definition rather than absolute weight loss and rebel against terms such as ‘fear of fat’, which they view as disempowering and effeminising (Derenne & Beresin, 2006). As a result of these earlier attempts to express eating disorders amongst men using the language and concepts of non-comparable disorders amongst women, there is a substantial lack of data on prevalence, incidence and burden of disease for men, with much of what is available difficult to evaluate, poorly reported or simple incorrect.

The message that there is no ideal size, shape or weight that every individual should strive to achieve is still largely targeted at women, and those campaigns which include men still prominently feature gendered iconography (such as the ribbon), further raising the barrier to access for male sufferers (Maine & Bunnell, 2008). Male body image is not as homogenous in the media (that is, there range for ‘acceptable’ male physiques is wider), but instead focuses on perceived or projected masculinity (Gaughen, 2004, 7 and Maine & Bunnell, 2008). More pressingly, there is no consensus in the literature regarding unique risk factors as they relate to gay or bisexual men; the US center for Population Research in LGBT health estimates prevalence in the LGBT community to be about twice the national average for women and approximately 3.5 times higher for men. At the same time, a similar research study (Feldman & Meyer, 2007) fails to establish an explanatory framework to address these findings, and a subsequent study (Hatzenbuehler et al., 2009) suggests that membership in the LGBT community offers some protection against psychiatric morbidity, including that from eating disorders. As mentioned above, a distinct lack of research is continues to present a barrier to drawing a broad conclusion on this topic.

Existing treatment for men with eating disorders occurs in a similar environment as that for women. Men living in isolated, rural or small communities who are experiencing violence that sometimes lead to eating disorders face barriers accessing the treatment, as well as additional stigma due to suffering from a ‘feminine’ disease (Public Health Agency of Canada, 2002). The Public Health Agency of Canada (2011 report) also states that integrated treatment approaches to family violence and eating disorders are likely to become increasingly scarce as the resources required to ensure accessibility to services, appropriate medical care, sufficient staffing, shelters and transition houses and counseling for underlying abuse issues are no longer available. Many cases in Canada are referred to USA for the treatments due to the lack of appropriate services offered (Vitiello & Lederhendler 2000). For example, in one case, a patient suffering from anorexia nervosa, originally admitted to The Hospital For Sick Children in Toronto was later recommended for a transfer to a facility in Arizona (Jones, 2007). In 2006, the province of Ontario alone sent 45 patients (36 of them male) to the US for eating disorder treatment at a gross cost of $ 3,719,440 (Jones, 2007), a decision motivated by the lack of specialized facilities domestically.

Speaking from the feminist relational position, Maine and Bunnell (2008) suggest a unique approach towards managing eating disorders in men. They advocate for counseling that focuses on how patients respond to pressures and expectations rather than on addressing the individual pathology of disordered eating. Current treatments in this vein show some success (Public Health Agency of Canada, 2011), but lack patient-based review and feedback. Monitoring of physical symptoms, behavioral therapy, cognitive therapy, body image therapy, nutritional counseling, education and medication if necessary are currently available in some form, yet all of these programs are delivered regardless of patient gender (Public Health Agency, 2002 and Maine & Bunnell, 2008). Up to twenty percent of patients with eating disorders eventually die of their illness, and another fifteen percent resort to suicide. With access to treatment, 75 to 80% of female adolescents recover, yet less than half of males do (Macleans, 2005). Moreover, there are several limitations in the collection of data, as most studies are based on clinical samples, which make it hard to tell about the findings to general population. People with eating disorders require a broad range of treatment for both physical complications and psychological issues, at a cost of about $ 1 600 per day (Timothy & Cameron, 2005, 100). Treatment for patients who were diagnosed following a hospitalization resulting from their condition is both more expensive (approximately three times more), and also less successful, with a corresponding drop of over twenty percent in women and forty percent in men (Macleans, 2005).