The information in this article originally appeared in an Equip Academy presentation. Watch the presentation here, and register for future Equip Academy events to learn about other eating disorder-related topics and earn free CE credits.

There’s no denying that the United States is in the midst of an eating disorder crisis. Since the start of the pandemic, there’s been a surge in these life-threatening illnesses, not just in the number of people affected but also in their acuity: since Covid-19 first hit, hospitalizations and length of stay have seen a 2x increase, and over half of eating disorder patients experienced worsening symptoms. Perhaps even more alarmingly, nearly 50% of adolescents with an eating disorder have considered suicide. This year alone, 5.5 million Americans will develop an eating disorder, but just 23% will get treatment and an even smaller fraction will get treatment that works. This is particularly difficult to accept, because we know that treatment does, in fact, work.

One factor perpetuating this crisis is misconceptions around who gets eating disorders. Despite evidence to the contrary, there’s still a pervasive belief—even among providers—that eating disorders primarily affect thin, white, cisgender women. In reality, this population is just the one most likely to get diagnosed and treated. Eating disorders impact people of all ages, races, body sizes, and genders. Boys and men make up a third of all eating disorder cases, and yet they continue to slip through the cracks. Let’s take a closer look at why that’s the case and what we can do about it.

Eating disorders and cisgender males: an overview

While boys and men account for a third of all people with eating disorders, less than 1% of eating disorder research includes males. There’s also significant shame and stigma around eating disorders in males, which interferes with timely diagnosis and treatment. Perhaps predictably, boys and men also report not feeling understood by their providers.

Eating disorder symptoms tend to show up differently in males versus females—which perpetuates underdiagnosis—but that doesn’t mean that eating disorders are less serious when they occur in men and boys. In fact, the eating disorder crisis may even be particularly pronounced in males.

According to one large study from Canada, hospitalization rates for males with eating disorders increased 416% from 2002 to 2019, and similar trends have been observed in the U.S. Another study found that among patients hospitalized for eating disorders, males tended to be in worse condition. Male patients had longer hospitalizations, lower heart rate, and higher rates of anemia than their female counterparts, likely due to a delay in getting diagnosed and treated as well as their higher macronutrient needs.

So how did we get here?

Exclusion of male experiences in early diagnostic criteria and research: A domino effect

It’s not an accident that boys and men with eating disorders often go undiagnosed and untreated. Rather, there were a series of decisions, events, and tendencies that led us to where we are today. Breaking them down in chronological order, we can clearly see the why behind the current state:

• Until recently, amenorrhea was listed as essential criteria for an anorexia diagnosis, causing many to go underdiagnosed.
• An anorexia diagnosis is also predicated on an extreme drive for thinness, fear of weight gain, and emaciation.
• Males who do get diagnosed with eating disorders are primarily diagnosed “by default” with EDNOS (now known as OSFED).
• Studies on eating disorders intentionally exclude males, as they were seen as “atypical.”
• Stigma and challenges with getting a timely and accurate diagnosis further hinder treatment engagement and research efforts around males.
• Very few residential treatment centers look at treatment outcomes in males.
• Current screening and assessment tools are not sensitive to the male experience of eating disorders.

Symptom expression of eating disorders in males

One of the biggest reasons that eating disorders in men and boys get missed is because their symptoms often present differently than they do in females. Providers are used to looking for the more common female symptoms, but many are not familiar with the symptoms that might signal an eating disorder among males.

Some of the differences in male presentation of eating disorders as compared to female presentation include:

• More likely to use anabolic steroids for muscle enhancement
• More likely to misuse exercise
• Less likely to misuse laxatives
• Less likely to use diet pills
• Eating-related symptoms are muscularity-oriented (i.e. overconsumption of protein-rich foods) vs. thinness-oriented
• Symptoms are driven simultaneously by acquisition of muscle mass and drive for leanness
• Greater weight fluctuations
• Hyperlipidemia common in adolescent males with eating disorders
• Co-occurring substance abuse more common

Equip recently published research on differences in symptom presentation and outcomes across gender. Our study showed that clinical presentation of eating disorders is different in cisgender boys and cisgender girls. Specially, we found that:

• Cisgender boys are more likely to be diagnosed with ARFID than cisgender girls (41% vs. 11%).
• Cisgender boys are more likely to have a secondary diagnosis of ADHD than cisgender girls (21% vs. 6%).
• Cisgender boys are slightly less likely to need weight restoration than cisgender girls (74% vs. 81%).
• Cisgender boys are less likely to endorse suicidal ideation than cisgender girls (18% vs. 28%).

Practice applications for treating eating disorders in males

Given all of the above, it’s clear that providers need to adapt their approach in order to better serve male patients who may be struggling with eating disorders. Research has shown that gender-specific adaptations to treatment improve outcomes, and using a gender-specific screening approach will almost certainly ensure that more boys and men get the diagnoses they need.

Screening and assessment considerations

When screening for eating disorders in boys and men, providers should keep in mind:

• A male patient’s inability to name or recognize eating disorder symptoms can hinder identification by a provider.
• The first point of contact for eating disorder treatment in males is usually a PCP (often for gastroparesis, arrhythmias, or low testosterone).
• It helps if a PCP is attentive, involved, non-judgmental, and avoids use of female-based information and resources.
• Assess for significant weight fluctuations, and don’t expect low weight or emaciation (though either may be present).

There are also some specific assessment tools that can be helpful in screening for eating disorders in men and boys. Specifically:

• Eating Disorder Assessment for Men (EDAM): This tool incorporates factors that measure symptoms more highly correlated to male behaviors, including depression, body dysmorphia, preoccupation with food, binge eating, and disordered eating.
• The Drive for Muscularity Scale: A widely used instrument that assesses men’s body image concerns and responses to societal pressure to be lean and highly muscular.
• Male Body Checking Questionnaire: A questionnaire to measure body checking behaviors in men, such as monitoring changes in muscles and muscle mass.

Treatment considerations

Treating eating disorders in males requires a different approach than treating eating disorders in females. When you’re considering where to refer a male patient with an eating disorder, it’s important to consider these factors:

• Male patients often report feeling isolated or unseen in (in-person) higher level of care settings. You can assess the risk of this happening by inquiring about any offerings specific to male patients (like groups, dedicated providers, etc).
• When available, patient-provider gender concordance (or other shared characteristics) may be helpful in addressing the shame and stigma that many male eating disorder sufferers experience.
• Providers must often skillfully address issues such as stigma, shame, body dysmorphia, drive for muscularity, maladaptive thoughts, and relationship with exercise.
• Male patients often warrant more aggressive caloric prescription at baseline, and more frequent escalations in order to achieve medical stability.

Eating disorders in males are common and serious, but—like all eating disorders—they are fully treatable, as long as providers take the right approach.

Schedule a call with our team to refer a patient or learn more about Equip’s evidence-based eating disorder treatment for boys and men.