Eating Disorders in Men & Boys

The Development of Eating Disorders in Males

Eating disorders are often considered a female illness, but the reality is that anyone of any age or sex can suffer from an eating disorder. The eating disorders of men frequently go overlooked and undiagnosed despite how men and boys suffer from their own body image issues, which can manifest as an eating disorder with its own risk factors, body ideals and presentation.

Body Image of Men & Boys

Men and boys differ from their female counterparts when it comes to body image. Males typically have a wider range of body ideals than females and perceive their weight differently, both of which can contribute to how an eating disorder can develop.

Male Body Ideals

Men and boys experience a wider variety of body ideals than women and girls. While females tend to only desire thinness, males desire a range of physique goals, including very thin, the extremely muscular and the lean muscular, which is the most commonly desired body type among men.

From a young age, the media showcases images of impossibly fit men with defined abs and lean muscularity as the male ideal, which has been shown to cause negative self-comparisons in consumers, with the goal to sell products to improve health, appearance, weight, muscularity and shape.

Perception of Weight

Unlike girls, who tend to perceive themselves as fat at more than 15-18% below population norms, boys learn to perceive themselves as fat at slightly above population norms. This when adolescent males who develop an eating disorder are most likely to begin their dieting. 

Because of the decreased pressure for boys to diet compared to girls, they tend to only do so under certain conditions:

• To avoid being teased again as they were for childhood obesity
• To increase sports performance
• To avoid developing similar weight-related medical illness as their father
• To improve a gay relationship

Men and women also tend to focus on different areas on the body. While women tend to be dissatisfied with their body from the waist down, men tend to be dissatisfied with their body from the waist up.

Risk Factors for Eating Disorders in Males

Risk factors for the development of eating disorders in men and boys include gay and bisexual orientation as well as sports, hobbies or work.

Gay & Bisexual Orientation

Research suggests that up to 42% of males with eating disorders are gay, significantly higher than the population as a whole, but still a minority of men with eating disorders. For gay men, a higher BMI, peer pressure, gender role conflict and lower levels of masculinity are associated with greater body dissatisfaction and disordered eating behaviors. Bisexual men have also been found to be more likely to engage in unhealthy weight control compared to heterosexual and gay men.

The use of dating apps is also a risk factor for both gay and bisexual men, likely due to the added pressure to achieve a certain body type to attract a partner.

Sports, Hobbies & Work

Males who participate in sports, hobbies or vocations that incentivize thinness for appearance and/or performance are more likely to develop disordered eating behaviors than their peers. Sports are a well-studied risk factor for the development of an eating disorder, with 19% of male athletes struggling with disordered eating behaviors and 8% previously diagnosed with an eating disorder.

Elevated rates of eating disorders are found in many sports, including:

• Wrestling
• Gymnastics
• Swimming
• Track and Field
• Equestrian
• Football.

Athletes with eating disorders can also be more difficult to identify and diagnose, due to stigma or a concern their athletic season will be disrupted by treatment.

Male Eating Disorder Statistics

Males with eating disorders have a different experience than their female counterparts. Men and boys are often undiagnosed and may feel stigmatized, which can impact their desire and ability to receive treatment.

Prevalence & Underdiagnosis

It’s commonly stated that males make up 10% of those with eating disorders, a statistic that only captures presentations at clinics and hospitals, which likely underestimates the prevalence of eating disorders in men and boys. Ratios of 3.6:1 (female:male) are found through population-based surveys, and an almost equal prevalence is found when female-based diagnostic criteria is removed and behaviors specific to males are considered.

However, more males are receiving treatment than ever before. From 1999 to 2009, hospitalization of males for eating disorders increased by 53%.

Age of Onset for Males

Males with eating disorders typically fall into three age categories:

• Child onset before 12
• Preteen through early twenties
• Young men and mature adults

The issues that prompt dieting and disordered eating in these populations vary greatly. Very young boys often express issues at home, like family conflict, moving or a change in the family dynamic, while adolescent men express difficulty with individual identity and wanting to improve aspects of their life like relationships, sports performance, entering the military or preventing weight-related illness.

While eating disorders are found across ages, most eating disorders in males develop in the teenage years or early twenties.However, dissatisfaction with body image can begin as early as six years old, with 32% of six-year-old boys desiring to be more muscular and 20% desiring to be thinner.

Stigmatization

Males with eating disorders are often stigmatized for their condition. There is a concern and shame among patients that they will appear less masculine for struggling with an eating disorder, which may cause men to delay seeking treatment.

Additionally, there remain health professionals who are uneducated about eating disorders in men and boys who may not recognize symptoms in males or diagnose males with an eating disorder. Some programs may not even accept male patients, further stigmatizing eating disorders in men and boys.

The Presentation of Eating Disorders in Men

The presentation of eating disorders in men is different from the presentation of women, primarily through many patients’ drive for muscularity rather than thinness.

Muscularity-Driven Eating Disorder

Muscularity-driven eating disorder (MDED) is a term for the combination of abnormal eating patterns and excessive exercise with the intent to achieve greater muscularity, with the fear of being too small. While MDED is not a diagnosis, it can be a useful term for men to use to describe their lived experiences.

In the last twenty years, numerous studies have focused on the drive for muscularity in males dissatisfied with their body image. In a survey of almost 15,000 young adults, 22% of males and 5% of females reported muscularity-focused disordered eating behaviors. Males are much more likely to desire increased muscularity than females but can also have a desire for thinness. While females tend to have a fear of gaining weight, males do not necessarily object to weight gain if it’s associated with increased muscle mass, more muscle definition or lower body fat.

Anorexia Nervosa & Bulimia Nervosa in Men

It’s estimated that 25% of those with anorexia nervosa and bulimia nervosa are male. However, this number could be higher due to underdiagnosis and stigma. Presentation of anorexia nervosa and bulimia nervosa in men is similar to women, as men restrict their food intake or engage in rigid food rules.

Where men differ from women is in their motivations. Women restrict their food intake to primarily achieve the thin ideal, whereas men may either restrict to achieve thinness or to become leaner but still toned, also known as “cutting (weight).”

Binge Eating Disorder

Binge eating disorder (BED) is the most common eating disorder diagnosis, with 36% of those with BED being men and boys.

Medical Complications in Males

Most of the medical complications for eating disorders are shared by males and females, with low testosterone being an exclusive complication present in male eating disorder patients, causing issues like gynecomastia and infertility.

Low Testosterone

Excessive exercise, particularly when it occurs alongside prolonged calorie restriction can cause a disruption in the male gonadal axis. Diminished luteinizing hormone (LH) fails to stimulate Leydig cells in the testes to produce testosterone, causing low testosterone levels, lowered sex drive and reduced sexual function.  Low testosterone can lead to fatigue, decreased muscle mass and reduced bone density.

Gynecomastia

This is a condition where the male breast tissue becomes enlarged. This can occur in males with eating disorders due to hormonal imbalances, specifically decreased testosterone levels.

Infertility

Low testosterone and malnutrition can cause a decrease in sperm count and quality, potentially leading to fertility issues.

Other Notable Conditions

There are other conditions which may not exclusively occur in men but can uniquely present in or impact men. These include osteopenia and osteoporosis, cardiovascular complications, muscle weakness and atrophy as well as co-occurring mental health issues.

Osteopenia & Osteoporosis

Many providers may not consider osteoporosis in a male patient because lower bone mineral density is associated more with women. However, males with eating disorders who are underweight for at least six months experience osteoporosis more than their female counterparts. Contributing factors for osteoporosis in men may include low testosterone, diminished calcium intake, lowered body weight, elevated cortisol and possibly other factors. Male patients with eating disorders should be tested for low bone mineral density using a dual x-ray absorptiometrys (DEXA) scan.

Cardiovascular Complications

Malnutrition and electrolyte imbalances put individuals with eating disorders at an increased risk of cardiovascular complications, including bradycardia and hypotension.

Muscle Weakness & Atrophy

Men with eating disorders may experience muscle weakness and atrophy due to inadequate nutrient intake and excessive exercise.

Mental Health Issues

Men with eating disorders are at a higher risk for developing other mental health disorders than their peers. Men with eating disorders are more likely to suffer from depression, anxiety and substance abuse.

Eating Disorder Treatment for Men

The core principles of eating disorder treatment are fundamentally the same for all genders. The main objectives are to restore the individual to a healthy weight, treat any psychiatric issues related to the eating disorder (such as anxiety, depression or distorted body image) and reduce or eliminate behaviors or thoughts that lead to insufficient or excessive eating and exercise.

Treating Medical Complications in Men with Eating Disorders

The medical treatment track for males doesn’t substantially differ from that of females, aside from treating a select few complications.

Nutritional Rehabilitation in Males

The typical goal for weight restoration in an inpatient setting is 3-4 pounds per week and 1-2 pounds per week in an outpatient setting. Calorie intake starts at 1,400-1,800 kcal/day and can be increased by 300-400 kcal every 3-4 days, and should be continuously evaluated based on the rate of weight gain. Additionally, weight gain can be supported with liquid supplementation in the early stages of refeeding.

Patients experiencing severe eating disorders or malnutrition are at an increased risk of developing refeeding syndrome during their nutritional rehabilitation and weight restoration. It's of critical importance to monitor lab values of phosphorus, potassium, magnesium and other substances for signs of refeeding syndrome.

Treating Osteopenia & Osteoporosis

Males with osteoporosis should be treated through weight restoration, strength training, restoration of testosterone and restoration of key vitamins and minerals.

At a restored weight, moderate exercise with low-impact weight bearing activities exert force on bone, which can help encourage bone growth. Resistance training is especially valuable as it improves morale; elicits feelings of contribution to goals; results in increased lean muscle mass and less abdominal fat deposits, leading to a decrease in remission and provides a healthy setting to work out with other men.

Important vitamins and minerals like calcium and vitamin D can be supplemented at 1,500 mg/day and 800-1,000 IU/day, respectively.

Treating Low Testosterone

Testosterone supplementation is an optional measure to treat low testosterone in men with eating disorders. However, it’s yet to be determined if testosterone replacement or a natural return of levels is more beneficial than the other. Extreme caution should be exercised in the use of testosterone replacement in males who are not close to full height or maximal bone growth, as it can cause premature closure of the bony growth plates.

Psychiatric Treatment for Men with Eating Disorders

While the core goals and treatment options for men aren’t very different than those from women, treatment may be tailored to address issues that are more prevalent or unique to men.

Male Group Therapy Sessions

Men may benefit more from mixed-gender or male-only group therapy options. In groups that are disproportionately female, the inclusion of male patients can be perceived as threatening or impeding on what’s regarded as a safe space for women. They may also be treated as a stand-in for an abuser. Together these can create an unproductive or hostile space for recovery for males with eating disorders. Male-only groups also have the added benefit of decreasing the stigma or perception of atypicality of males with eating disorders, allowing men to discuss their lived experiences, talk about the cultural messaging around the ideal male body and build relationships with other men.

Addressing Feelings of Stigma

Men with eating disorders often face societal stigma, as these disorders are frequently and inaccurately perceived as exclusively affecting women. Therapists and other healthcare providers should be sensitive to this and work with male patients to address these issues.

Incorporating Male Body Image Concerns

Men often face different societal pressures around body image, with a greater focus on musculature and leanness. Treatment for men often needs to address these specific concerns instead of defaulting to the female experience, which is found in many eating disorder treatment programs.

Treating Co-Occurring Psychiatric Conditions

Men with eating disorders are more likely to have co-occurring conditions like substance use disorders. This should also be addressed by a multidisciplinary treatment team.

Treatment Engagement

Some studies suggest that men may be less likely to seek help for an eating disorder due to the stigma associated with these conditions. Healthcare providers may need to use different strategies such as emotion-focused therapy and education on the impact of the muscular-oriented male body image toward disordered eating patterns, ultimately ensuring that men feel engaged, comfortable and understood.

Treatment Outcomes for Males with Eating Disorders

Males and females respond similarly to treatment, with findings suggesting men have similar or better treatment outcomes compared to women. Men also experience a similar remission rate for anorexia nervosa, but a slightly lower remission rate for bulimia nervosa. Males with anorexia nervosa also score lower on standardized testing and subscales of the Eating Disorder Inventory, with lower scores on interpersonal distrust and perfectionism.

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Last Reviewed: December 2023 by Dennis Gibson, MD, FACP, CEDS