I was always the tallest kid in my class, a not-so-subtle feature of mine I liked quite a bit. I would look at my growth chart and projected adult height and feel on top of the world (almost literally). I had a bit of a belly, as many kids do, but it didn’t bother me much—until, suddenly, it began drawing unwanted attention. As I got older, kids started to comment about my weight in a rather malicious way. I tried not to let it bother me, but that became increasingly difficult. I continued to gain weight, and when the next-size-up pants didn’t fit, my mom suggested I try a “husky” fit (for those who didn’t live through it, “husky” was a sizing category for boys in bodies that were larger than “normal” sizing could accommodate). I couldn’t pretend to be unbothered anymore.

Was I husky? What did that even mean? I wore the pants, begrudgingly, feeling self conscious and unhappy about the way I looked. I began trying to change my body: I dabbled in diets in middle school, then started working out more intensely in high school in an effort to lose weight.

But nothing really stuck until college, when I became more diligent about dieting and exercise and lost a significant amount of weight.

After losing the weight, I distinctly remember finishing some laps at our community pool and a neighbor commenting to me that I looked “athletic.” As a nerdy Jewish kid with poor hand-eye coordination, I couldn’t remember ever hearing my name and the word “athletic” in the same sentence. It felt great. I went back to the locker room and flexed in the mirror, noticing the tone of my muscles. That seemingly innocuous comment reinforced the efforts I’d been making, and I doubled down on my weight lifting, biking, and dieting.

Although I never met formal criteria for an eating disorder, I could see my behaviors becoming unhealthy. And like so many men who remain undiagnosed or are diagnosed late, I couldn’t see the negative effects my behaviors were having.

How eating disorders present in men and boys

Although many people perceive eating disorders to overwhelmingly affect women, about one in three people with an eating disorder identify as male, and an estimated 10 million American men will have an eating disorder at some point during their lifetime. Men and boys are also nearly as likely as women to have disordered eating behaviors that don’t meet criteria for an eating disorder. Despite all this, men and boys are far less likely to seek treatment for eating disorders than women and girls.

There are several reasons for this discrepancy including stigma and gender differences in presentation—meaning the way eating disorders tend to show up in men and boys vs the way they tend to show up in women and girls. Men with eating disorders generally have a later onset of illness than women, with eating disorders usually developing later in their teenage years. In terms of eating disorder behaviors, men are less likely to struggle with “emotional eating,” to report out-of-control binge eating, or to use laxatives or induce vomiting than women.

Men and boys who seek treatment for eating disorders are less likely to say they have body dissatisfaction, and generally strive to be lean and muscular as opposed to thin. In the newest edition of the DSM (the handbook containing information detailing all psychiatric disorders), there’s a description of “muscle dysphoric disorder,” which is characterized by a preoccupation with the idea that one’s body isn’t sufficiently muscular and behaviors like dieting, weightlifting, and steroid use. Muscle dysphoric disorder isn’t considered an eating disorder, and there’s controversy over whether it should be; however, the fact is that men with muscle dysphoric disorder have similar rates of weight concerns and restrictive dieting as men with anorexia.

Risk factors for eating disorders in men and boys

First off, it’s important to note that eating disorders don’t discriminate: they affect people across gender, age, race, socioeconomic status, body size, and more. However, there are certain characteristics that are associated with an increased risk of developing an eating disorder in men and boys.

Men with eating disorders often have a history of being “overweight” when they were younger. Interestingly, obesity in boyhood is associated with greater risk for development of an eating disorder later in life. And although many women with eating disorders have a perception that they were overweight, more typically they have a “normal” weight history.

Another important consideration is history of sexual abuse, as an estimated 30% of people who struggle with an eating disorder experienced sexual abuse at some point in their lives. Men are less likely to report sexual abuse than women, most likely because of increased feelings of shame and stigmatization. Because most perpetrators of sexual assault are men, men and boys who are victims of sexual assault often experience conflicts related to their sexuality and sexual orientation They may cope with those conflicts by restricting what they eat in order to delay the development of secondary sex characteristics. Body image distress is also more common in men who were victims of sexual abuse.

Sexual orientation and gender identity also come into play. Although an estimated 5% of the total population of men identify as gay, that number is 42% among men with eating disorders. Men who identify as gay or bisexual are also more likely to have eating disorder behaviors than heterosexual men. Interestingly, gay men who report feeling connected to the gay community are less likely to have eating disorders than those who do not.

The relationship between gender identity and eating disorders is complex, and there are relatively few studies examining eating disorders in transgender individuals. However, the evidence that does exist reveals much higher rates of eating disorders in transgender people compared to those who identify as cisgender. One study found that gender non-binary individuals were over three times more likely to have a diagnosed eating disorder relative to those with a binary gender, while another found transgender college students had significantly higher rates of self-reported eating disorder diagnoses compared to heterosexual cisgender women. Some transgender folks report a desire for thinness as a way to alter their gender expression, and that gender reassignment procedures led to an improvement in some disordered eating behaviors.

Overall, despite the fact that men and boys represent a significant proportion of people with eating disorders, many—perhaps the majority—go undiagnosed and even fewer seek treatment. One of the first steps toward changing this reality is educating both the public and healthcare providers about the different and unique ways that eating disorders show up in men and boys. The sooner we can throw out stereotypes and see eating disorders in the many different ways they show up in all populations, the sooner we can get treatment to everyone suffering.