When I started asking other therapists about the idea of why there was such a gender difference in seeking therapy, out of the blue came a study by two Psychologists at Oxford University, Ulla Raisanen and Kate Hunt. Their study was called “The role of gendered constructions of eating disorders in delayed help-seeking in men: a qualitative interview study”.
The objective of the study was to understand how young men recognise they have an eating disorder, then whether or not they seek help for it. Most of the volunteers were students aged between 16 and 25. The eating disorders studied were Anorexia Nervosa, Bulimia Nervosa, Binge eating and EDNOS (Eating disorder not otherwise specified).
Anorexia Nervosa has one of the highest mortality rates of all the psychiatric conditions during adolescence (1), It costs NHS about £50 million in inpatient care and an additional £5-20 million for outpatient care. So spotting the condition early can help with the care available and the long-term prognosis.
So when the question was asked about the difference in the proportion of men to women who had been diagnosed with an eating disorder, it took two paths: One was looking at the training amongst health professionals in diagnosing and treating the problem (2) and the other in the public perception of eating disorders, and the amount of information and quality of information available.(3)
Previous studies focused on exercise, body image, dieting practises and sexual orientation, or on eating disorder services provided. (4). This study however concentrated on:
- How do men make sense of their early (and later) signs and symptoms of disordered eating?
- How do they realise something might be wrong and require intervention?
- Are there perceived barriers to accessing primary care (or other) services for men with EDs?
- What are mens experiences of health professional’s responses to their initial presentations of ED signs and symptoms?
Only 10 men took part in the study, which shows to some extent the numbers used in trials such as these, 8 were white British, one Latino and one mixed race, 6 were students, 2 employed and 2 unemployed, 3 were homosexual.
The first part of the interview allowed the interviewee to just talk about his experience and then the second part was more questionnaire based.
The results showed that all of the men took some time to recognise their behaviours as a symptom of an eating disorder. Those with Anorexia Nervosa (AN) started generally by skipping meals, restricting their calorie intake and eventually go for days without eating anything. Those with Bulimia Nervosa (BN) started to comfort eat and purge and gradually built it up to be habitual. Their daily routines revolved around obsessive calorie counting and exercise regimes, and weighing. Often they experienced other problems such as self-harm and isolation.
The 10 men explained their actions as so:
1) Did not think he had a problem.
”I didn’t know men could get eating disorders then …cos that would be like I’ve years ago and there wasn’t really much said about men with eating disorders then didn’t know the symptoms, didn’t know anything, it was just, to me it was just happening. I didn’t really know what was going on”
2) He did not interpret his disordered eating behaviours as symptoms of an illness, or as anything recognisable and treatable; rather he saw his symptoms as mundane aspects of his life, something that was just happening.
“like you hear like the side effects of having an eating disorder on like women. Like they can become infertile and stuff like that, but I’ve never seen any for men. So I like went and was like ‘Look, well what are they for men?‘ Cos like that I could like have a side effect and I wouldn’t know. I think I read somewhere that men can become infertile by it, and I’m like,‘Yeah but no one tells you that’. They need to like tell you ‘this could happen, that could happen. Like you can get, I know you can get like osteoporosis which I’ve only seen like written about women, which is obvious it could happen in men as well. So it could lead like some people to think, ‘Oh there’s no side effects for men.’ When there is and it’s just not, you just can’t, I think, I had to like scroll through the whole of the Internet trying to find bits of information.”
3) The idea of an eating disorder did not enter his head. His parents suggested he was just “being silly”, about his eating.
4) He developed his bingeing and purging as a coping mechanism and thought he’d invented it.
”I thought I made it up myself you know, something that only I did, you know, I never thought in a million years this was something that lots of people did, and deliberately did to cause damage to themselves. You know, it wouldn’t have crossed my mind.”
5) He thought ED was something highly emotional teenagers suffered with, not “one of the lads” who played Rugby.
6) He had been investigated for gastric problems to his purging; no one including his parents and clinicians suggested it was psychological.
“The only information I got was [er] a scare sheet basically. It was this was going to happen if you keep going. Basically the big one that they circled was, Oh you won’t be able to be sexually active’ for men. And that was the biggest thing. I got about five or six different sheets from them, and basically the main fact was, ‘Oh yes, your organs won’t work, you know. You’ll lose nails, hair will thin. You cannot have sex’’.
7) He thought people at school knew about his problem but it was something not discussed. He knew for a long time that his habitual bingeing and purging were causing problems, but had no name or understanding to make sense of it.
”I didn’t really know what, where to go or what to do to be honest. [Um] We’ve all heard of the like, female anorexia and all of that. And everyone, I think I’d heard of anorexia [um] that isn’t what I was going through as such. And I didn’t really know what it was or where to go. I did start googling it and I came across [um] eventually on Facebook that men have eating disorders too, as well, and there was a couple of other websites that I looked at. [Um] But there’s still in my opinion there’s still no real information of what you do or where you go”.
8) He became more introverted and isolated and then realised things were “not normal”.
9) He became gaunt and his spine protruded, and it was only during an emergency home visit from his GP was he told to admit himself to hospital otherwise he’d be sectioned. He had seen his GP before, and they had wanted to weigh him, but he refused so nothing happened next.
10) He had restricted food intake and was losing weight when his girlfriend forced him to re-evaluate his behaviour.
In addition to delaying seeking help, there was also the fear of not being taken seriously. There may also be history in a GP not helping with a previous unrelated problem. In some cases there was a reluctance to relinquish behaviours as they felt it was something they couldn’t live without.
It was a positive experience with a healthcare worker, GP or counsellor which dictated what happened next, one GP just wasn’t able to offer any help as her area did not provide any services!
Some had to visit their GP several times before being taken seriously another had tried to commit suicide before being admitted to A&E and was immediately referred to intensive outpatient treatment. (5)
There are many resources for eating disorders such as – http://www.nationaleatingdisorders.org, but as therapists we can help highlight, not only eating disorders but other mental health problems that are suffered by both genders. One aspect was highlighted whilst reading through this and that is the idea of the stereotypical male, that they should be “man” about problems, and to show weakness was frowned upon. Hopefully these stereotypes are gradually being changed over time, despite having been popular for over 50 years now, it may take another to truly filter down, but let’s hope it shorter.
References:
- National Collaborating Centre for Mental health.
Eating disorders: care interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders
. London: The British Psychological Society and Gaskell, 2004.
- Greenberg ST, Schoen EG. Males and eating disorders: gender-
based therapy for eating disorder recovery.
Prof Psychol Res Pract 2008;39:464
- Hara SK, Smith KC. Presentation of eating disorders in the news /
media: what are the implications for patient diagnosis and treatment? Patient Educ Couns 2007;68:43
- Drummond MJ. Men’s bodies throughout the life span. In: Blazina C,
Miller D, eds. An international psychology of men theoretical
advances, case studies, and clinical innovations. Routledge, 2011:159
Drummond MJ. Men, body image, and eating disorders. Int J Men
Health 2002;1:89
Drummond MJ. Understanding masculinities within the context of
men, body image and eating disorders. In: Gough B, Robertson