What about the boys?: addressing issues of masculinity within male anorexia nervosa in a feminist therapeutic environment.
Keywords: male anorexia nervosa, masculinity, feminist therapy, social stigma, DSM-IV
Anorexia nervosa is typically understood as a culturally motivated psychological disorder of young women, with 90 percent of diagnosed cases typically found in the female population according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychological Association, 1994). As a result of this association as a "female" problem, and the low incidence of anorexia nervosa in men, past research on the disorder has mainly been done with female subjects. Various ways in which anorexia nervosa can be treated are also part of this past research and these treatments mainly focus on the medical, psychological, and social conditions of female anorexics. Current scholars are now finding that this research on the many facets of anorexia may not be applicable to the male anorexic population, and consequently have implications for treatment of the disorder. Anorexia nervosa among men is, in and of itself, a unique problem that must be addressed in a way that is appropriate for the male patient and his gender-specific emotional, psychological, social, and cultural issues.
It is impractical to think that men completely escape social pressures of aestheticism, especially as more and more evidence points to an intensified connection between men and their bodies: how their bodies are represented and how men feel about their bodies. In light of the gender specificity of anorexia nervosa and increasing attention to the male body as an aesthetic object, I believe the path to successful treatment of anorexia nervosa in males is to regard it as its own disorder with treatment that addresses the gender bias which surrounds it. By incorporating related concepts of masculinity theory and body image, as well as attending to the related pressures that some athletes and homosexual men confront, the basis for a male-centered approach to the treatment of anorexia nervosa can be developed by addressing concepts previously ignored.
One of the reasons for the lack of an effective, psychosocial approach to anorexia nervosa in males is that psychologists rarely considered the disorder to be a valid diagnosis in men. Physicians, as well as men who suffer from the disorder, are often unaware that anorexia nervosa could occur in both genders (Goodman, Blinder, Chaitin, & Hagman, 1988). The very notion that anorexia nervosa is not acknowledged as a legitimate problem for young men must be addressed in future treatment developments for anorexia nervosa. Furthermore, whereas the obsession with thinness is seen as "normal" for a woman, a man's preoccupation with his body is seen as an abnormal identification with the feminine (McVittie, Cavers, & Hepworth, 2005). McVittie et al. (2000) examined the ways in which male college students comprehend anorexia nervosa in men and supported the notion that society as a whole still views this disorder as a condition predominantly found in women. Since everyday understanding of anorexia nervosa strongly associates the disorder with femininity, it has been difficult for men who suffer from the disorder to come forward out of fear they will not be taken seriously or that they will be thought of as "less masculine" by social standards. The stigma of anorexia nervosa as a "female problem" also prevents many male anorexics from even understanding that they have an eating disorder. As a result, treatment approaches for anorexia nervosa in men rarely address social or cultural implications surrounding their symptoms. Instead, therapists focus on gender-neutral psychotherapy techniques, cognitive rehabilitation, and nutritional counseling for the male anorexic. Even if some of the psychological and biological aspects of the disorder itself may be effectively addressed (as they are in females with anorexia nervosa), traditional approaches fail in several ways: they often leave out the social and cultural pressures that men internalize and express through their anorexia; they do not consider the social expectations of masculinity on male body image; and they do not acknowledge the increasing public awareness of anorexia nervosa in men.
Although the women's movement has been moderately successful in alerting young women about the social construction of ideals of feminine beauty as it relates to their bodies, nothing equivalent has been available regarding the construction of masculine ideals. It is important for young men to learn about the way society can alter their self-image. Additionally, we must educate the psychologists seeking to help these young men about the role society plays in boys' adolescent development. I suggest a new approach, which incorporates effective feminist psychotherapy basics with masculinity education, in order to address the psychosocial aspects of anorexia in men that are directly related to the social construction of gender.
The Progression of Anorexia: From Fasting Girls to "Looking Anorexic"
The earliest documented accounts of anorexia, literally meaning "loss of appetite," date back to the 17th century. In 1689, Richard Morton recorded the first case of sudden loss of appetite, without reason of medical disease, in an adolescent male (Silverman, 1990). Interestingly, this report also had a female account of anorexia, but while the female instance is well known, the male episode seems to have become lost (Silverman, 1990). Seventy-five years later, Robert Whytt documented a case of a young man who was "wasting away," with accompanied depressed affect. In 1790, Robert Willan outlined the 78-day fast of a young man, describing the psychological and physical difficulties he suffered as a result of malnutrition. These three documents imply that occurrences of anorexia have been present in men as long as women.
How then, did this phenomenon of anorexia become commonly known as a "female problem"? In Fasting Girls, Joan Brumberg (2000) discusses various cases of loss of appetite in young women throughout the centuries, outlining the history of this condition, from speculation of anorexia mirabilis among saints ("miraculously inspired loss of appetite") to the emergence of anorexia nervosa. "Anorexia nervosa" was first coined as a diagnostic term by William Gull in the late 19th century (Brumberg). Ultimately, after assessing female cases referred to him from psychologists who found themselves at a loss for diagnosis, Gull asserted that anorexia nervosa was to be defined as an independent disorder that needed exclusive attention (Brumberg, 2000).
Feminist concepts began to emerge surrounding the disorder with direct correlations to women's existence in society and the expectations placed upon the female body during the 19th century as anorexia nervosa continued to become an epidemic condition among young women (Brumberg, 2000). The Victorian woman was to be quiet, thin, and proper (e.g. eating small portions, because it was lady-like). Controlling her appetite was a way for a young woman to speak about the difficulties she faced conforming to society's pressures. At the same time, social trends began to connect a woman's ability to be loved with her appearance. In the Victorian era, food was connected to "gluttony and to physical ugliness" (Brumberg, p. 176), and Victorian norms suggested women should never been seen eating. As a result, women distanced themselves from food and internalized the idea that having an appetite was not natural. Instead, withholding one's appetite became a way for the Victorian woman to assert her place in society as a proper woman, which led to cases of "secret eating."
Many of the implications of 18th and 19th century ideals have persisted into current theories which address anorexia nervosa among females in a sociocultural context. Pressures of ideal body image and social constructions of gender are of great importance in understanding how anorexia nervosa manifests itself in the female population today. Increased frequency of media images which emphasize "perfect" female bodies contribute to a culture which allows for an acceptance of disordered eating. Fister and Smith (2004) investigated the effects of exposing young women to thin models on eating pathology in comparison to women in a control group. Those women exposed to images of thin models were more likely to endorse expectations of thinness in their own lives. In other words, repeated exposure to thin models in the media had a significant effect on the internal beliefs and expectations of the women who were being studied. Stice, Schupack-Neuberg, Shaw, and Stein (1994) conducted survey research that assessed the effects of media exposure on gender-role endorsement, ideal-body stereotype internalization, body dissatisfaction, and eating disorder symptoms in 238 college undergraduate females. Results supported previously suspected connections between the pressures to achieve thinness, as portrayed in media images, and eating disordered behavior. There is wide acceptance that these oppressive images of how a female body should look, based on an impossible ideal, contribute to the anorexic culture we find ourselves in today.
Feminist theory connects anorexia nervosa in young women to the social oppression of women as a gender, the power structures in society which force women to be subordinate to men, and, most currently, the pressures of ideal body image within Western culture. While previous eras have valued the thin body, as cases of anorexia throughout the 17th, 18th, and 19th centuries suggest, one cannot assume that these occurrences resemble the current obsession with thinness that existed in the 20th century and continues into the 21st century (Seid, 1994). Never before has the ideal body become so thin, so unlike that which is naturally feminine (e.g. full breasts, curves, wideset hips). In fact, "the ideal body weight has progressively decreased to that of the thinnest 5-10 percent of American women. Consequently, 90-95 percent of American women feel that they don't measure up to social expectations" (Seid, 1994, p. 8). Due to the normalization of a body image that deviates from that of the average woman, it causes many women to feel as though they are abnormal. For some women, this obsession can yield disordered eating habits which can easily spiral into anorexia nervosa. Decades ago, anorexia nervosa was a disorder about which most people knew very little; today, "nearly everyone understands flip remarks such as 'You look anorexic'" (Brumberg, 2000, p. 11).
Objectified Body Consciousness: A Way to Understand Body Dissatisfaction
One way to understand what it means to "look anorexic" today is by considering the way people experience their bodies as socially influenced objects. Nita Mary McKinley (2002) has developed a concept called "objectified body consciousness," which takes into account factors such as body surveillance, the internalization of cultural body standards, and appearance control beliefs. This measure is strongly connected to feminist theoretical notions which articulate that women and girls perceive their bodies as objects to be watched. It also allows for a better psychological understanding of the reasons young women develop extreme cases of body dissatisfaction, which can frequently develop into eating disorders.
Body surveillance involves looking at oneself as though separate from the body; it is about measuring oneself against a set of standards, and trying to meet these standards. If these standards are not met, a woman often feels bad about her body (because it is perceived to be different than what is most valued in society) and she quickly becomes more susceptible to the influence of others. This influence is deeply rooted in the second part of objectified body consciousness, the internalization of cultural body standards. By seeing cultural standards as equal to her own desires for her body, a woman finds that liberating herself from these obsessions becomes increasingly difficult. Her ability to meet internalized standards is strongly associated with her perceptions of self-worth, turning the body into a standard by which her self-worth is measured. Lastly, appearance control beliefs serve to manipulate the mind into thinking that these cultural standards are achievable (McKinley, 2002). Through these beliefs, society is able to justify the ways in which women's bodies are objectified and judged.
This concept of objectified body consciousness can also be associated with an increase in male body dissatisfaction, especially when related to the current cultural expectations for the male body. More than ever, male identity is connected to the male body. Images of Abercrombie and Fitch models with perfect abdomens, arms, and chests, Calvin Klein underwear ads strewn across Times Square, and men's interest magazines (that often encourage achieving goals such as heterosexual dominance and muscular definition) at every check out counter contribute to Western culture's increased focus on the male body. An emphasis on the athletic body valued as the ideal image in almost every facet of popular media also lends itself to this cultural obsession. Studies show that young men have body image preoccupations that are more centered on body shape, rather than low weight or clothing size (i.e., a number), which is characteristic of females who have anorexia nervosa (Muise, Stein, & Arbess, 2003). These conclusions serve to reinforce the concept that women feel their bodies must be a certain size, but men feel their bodies must satisfy a certain objectified combination of leanness and muscularity. This body-obsessed culture increases the possibility of eating disorders in men as well as women.
Men and Masculinities: Why Is It Important to Talk to Our Boys about Their Bodies?
Susan Bordo (1999), in her book, The Male Body, argues that "beauty has (re)discovered the male body" based on the observation that men are being put on display more frequently in society (p. 168). Advertising has always been one of the main places for female objectification and now, men are feeling the pressure of obtaining a "perfect" body. There is a role reversal in the sense that women are becoming the observers of these men on display, who are dressed, for example, in nothing more than a pair of white Calvin Klein boxer briefs.
What does this kind of shift in social expectation do to young boys in terms of body image? Let us first understand that, for many years, boys were not perceived as being connected to their body. Instead, men have been associated with the mind: the realm of rationality, control, and logic. To connect a man with his body would mean to connect him to the irrational, the uncontrollable, and the illogical. The body is a woman's sphere. Even Bordo (1999) confirms that "it's feminine to be on display." Now, men are beginning to see that their bodies matter socially as well.
The depictions of male bodies in advertising do not stray far from those of female bodies, particularly when the focus of the ad is clearly about the body itself. These similarities in presentation give a reason to assume that men may begin to feel similar body image pressures as a result of being bombarded with these ads. For example, Calvin Klein features an underwear ad with a two-story high photograph of a man with a chiseled abdomen, perfect pectoral muscles, and practically no body fat. This ad would catch the attention of most people walking down Broadway in New York City. Similar ads are found in men's and women's magazines, telling both genders that the way you look is important to who you are and how people perceive your value. Women, of course, have been subject to this association between body and social value for quite a long time. However, men are beginning to feel the burn.
Men's bodies have long been perceived as "active," with emphasis placed on what men can do with their bodies, rather than what their bodies look like. Contrarily, women's bodies have always been passive receivers of the public eye and subject to aesthetic judgement. Now, however, "the athletic, muscular male body that Calvin plastered all over buildings, magazines, and subway stops has become an aesthetic norm" and young men across the country are feeling the effects (Bordo, 1999, p. 180). In extreme cases, psychologists are finding that more and more young men are internalizing these social pressures to be thin and "perfect" (Drummond, 2002). As a result, eating disorders have become a growing problem for young men.
To my knowledge, there is no gender-focused psychotherapy approach that focuses on the social construction of masculinity and how these pressures affect a young man's development of body image, directly relating to the emergence of anorexia nervosa in males. It is important that psychologists apply knowledge of the social structures that contribute to the construction of masculinity in order to better address the problem of anorexia nervosa in young men (Drummond, 2002).
What Exactly Is Anorexia Nervosa?
Eating disorders often develop when distorted perceptions of the body become psychologically damaging, particularly in the crucial developmental stages of adolescence. So, what does it mean to be an "anorexic" and suffer from the psychological disorder that is becoming so commonplace in today's society? A diagnosis of Anorexia Nervosa requires the satisfaction of four main criteria (American Psychological Association, 1994). First, the patient exhibits a refusal to maintain a body weight at or above 85 percent of what is normal for his or her height and age. Second, the patient shows an intense fear of gaining weight or becoming fat. This fear is usually based on irrational connections between food, fat, and the body. Third, the patient harbors distorted perceptions of self-body image and weight; the patient's body is often the only thin body s/he sees as fat.
The fourth criterion carries clear gender-bias in diagnosing a patient with anorexia nervosa. Delayed menses or amenorrhea, which is the absence of menstruation for more than three cycles, is a physiological sign that usually supports a diagnosis of anorexia nervosa (American Psychological Association, 1994). However, this criterion applies solely to females, since men do not experience a menstrual cycle. There is no documented equivalent for the male patient suffering from symptoms of anorexia nervosa. It is possible that this can lead to insufficient diagnosis or an unclear understanding of the disorder among men, resulting in satisfaction of only three of four diagnostic criteria. Researchers suggest that lowered levels of testosterone, resulting in weakened sexual desire and performance, could be considered a parallel diagnostic factor, based on the consistency of this condition among male anorexic patients (e.g., Muise et al., 2003).
It is very typical for those who suffer from anorexia nervosa to have other mental disorders existing concurrently with their eating disorder (known as co-morbid disorders). Common co-morbid disorders with anorexia nervosa, in both men and women, include obsessive-compulsive disorder, bipolar disorder, and major depressive disorder. Obsessive-compulsive behaviors focus mainly on body image, food, and weight (Ray, 2004). Low self-esteem is often associated with co-morbid mood and personality disorders, contributing to an anorexic's distorted body image and negative self-evaluation.
A toxic family environment also contributes to the maintenance of an eating disorder. Families who place excessive emphasis on appearance and self-control are particularly triggering to the development of eating disorders (Halperin, 1996). Therapists also found that anorexic children are often "enmeshed with their parents" and strive for perfection and approval. When parents do not provide this approval, anorexia becomes a way for a child to deny the failure and feel powerful (Halperin, 1996). As a result of these pressures, toxic family environments significantly damage the success of individual treatment among anorexic patients (Ray, 2004). The inclusion of family therapy in the treatment of anorexia nervosa is a way to buffer these effects on the male anorexic, addressing reasons such as these that could be toxic to healthy body image perceptions.
Feminist Psychotherapy of Anorexia Nervosa: A Win for Women, a Loss for Men
Upon diagnosis, treatment approaches are discussed based on the individual needs and circumstances of the patient and usually encompassing various techniques, such as partial or inpatient hospitalization, individual and group therapy, nutritional counseling, weight restoration, and/or drug treatment. Various schools of psychological thought approach anorexia nervosa from different theoretical avenues. For example, cognitive-behavioral theorists see anorexia nervosa as a disorder rooted in distorted perceptions of body image and food that can be adjusted in combination with weight restoration and nutritional counseling (Fairbum, 1985). Interpersonal theorists address anorexia nervosa as an outward manifestation of problems involving personal relationships. To best exhibit the current proposal for a male-focused, psychosocial approach to the treatment of anorexia nervosa, it is important to first examine how the disorder has been traditionally understood and gendered as a "female problem."
Feminist psychotherapy is a treatment approach that takes into account the assumption that social and cultural environments contribute to the prevalence of anorexia nervosa among young women today. Enns (1997) makes the distinction that feminist psychotherapy differs from other approaches in its ability to acknowledge the environment within which a person exists and how that environment contributes to the development of certain behaviors. General concepts included in treatment approaches within feminist psychotherapy, such as empowerment and acceptance, have been shown to benefit male patients dealing with various psychological problems (Ganley, 1988). In fact, feminist analysis has been very beneficial to the treatment of these men because it stresses that men have different experiences than women, due much to the social construction of gender. For example, in Western cultures, boys are subject to pressures to provide for a family and remain in control of their emotions, pressures that women do not normally feel to such an extent in most cases (Ganley). However, some techniques within feminist psychotherapy that address the specific problem of anorexia nervosa leave men who suffer from this disorder completely out of the picture, by focusing on women's oppression and the demands of society for women to have the perfect body.
Feminist psychotherapists who treat anorexia nervosa see symptoms as communication tools for the client (Enns, 1997). The client is recognized as behaving to the best of her ability in a restrictive environment (Enns). She communicates her struggle through her eating disorder; her symptoms are her speech. Feminist psychotherapy techniques that address anorexia nervosa also make a strong connection between the construction of femininity and food. Deep associations exist between emotional satisfaction and a woman's relationship with food. Love and comfort are emotions associated with the feminine and food becomes a way for women to express these emotions to their families (Enns).
Anorexic women engaged in feminist psychotherapy are taught about a woman's relationship to food as a result of her socially constructed femininity. As a result, they are better able to understand their own preoccupations with food, attributing them to cultural standards and socialization. Once the anorexic understands the basis for her fears and obsessions with food, she can begin to adjust the way she incorporates food in her life. No longer will it be a source of emotional expression. For the anorexic female receiving feminist therapy, food will eventually become detached from her femininity and reintroduced to her as a source of nutrition necessary for her body.
Feminist psychotherapy also draws convincing connections between anorexia nervosa and idealized notions of the social and sexual body of a woman (Orbach, 1985). Society sees the female body as an object to be molded to fit social expectations and consumed for sexual satisfaction. Women often buy into these expectations and internalize them, thus creating distorted body perceptions by adopting the idea that a "perfect body" is a thin body. The mirror becomes her worst enemy. A woman caught in the middle of such unstable social swings will clearly never feel like she measures up. Orbach claims that psychologists need to understand the relationship between a woman's psychology, her feelings of inadequacy (put upon her by society), and her need to seek and acquire the "correct" body, in order to properly understand the social underpinnings of anorexia nervosa in women.
These concepts, which are so effectively implemented in the feminist treatment of anorexia nervosa in women, have little relevance to cases of male anorexia nervosa because of the intensified focus on femininity, as opposed to the social construction of both genders. Feminist psychotherapy techniques do not aim to address the relationship men have with food because men are not seen as having an emotional connection to food. Nor do these techniques aim to address issues of inadequacy felt by young men, as they are surrounded by pressures of ideal male bodies more than ever. Research supports feminist psychotherapy as a beneficial approach to women with anorexia nervosa, based on its ability to treat symptoms of eating disorders by concentrating on social constructions of femininity, but feminist psychotherapy has not yet taken these concepts into the realm of masculinity to accommodate the male anorexic. Part of the reason for these deficiencies is that feminist psychotherapy approaches to anorexia nervosa focus on women. These deficiencies, combined with the existence of feminist psychotherapy as the only gender-specific approach to eating disorders, leave male anorexics with no gender-specific techniques that distinctively address the psychosocial aspects of their disorder.
Anorexia Nervosa in Males: A Focus on Homosexual Men and Athletes
In order to develop an effective gender-specific treatment approach, it may be helpful to examine the incidence of body image and disordered eating behavior in two groups of males that are known to psychologists as susceptible to developing anorexia nervosa: homosexual men and athletes. Among men who identify as having anorexia nervosa, there is an established higher occurrence of homosexuality (10-42 percent) than in the general population (approximately 6 percent) (Russel & Keel, 2002). The study predicted homosexuality to be a specific risk factor for eating disorders in men. This study excluded bisexual men, only comparing heterosexual men to homosexual men. The ages ranged from 18 to 50 years. Whites comprised 71.3 percent of the sample, while 7.4 percent were African-American. Additionally, 32.8 percent were students, and 28.7 percent were professionals. Out of the total sample, 68.6 percent of these men had completed a bachelor's degree. Overall, the researchers classified their sample as a "large, diverse community-based sample" (Russel & Keel, p. 305). Findings concluded that "sexual orientation continued to account for a significant portion of variance in measures of body dissatisfaction, anorexia and bulimic symptoms, after controlling for depression, self-esteem, and comfort with sexual orientation" (Russel & Keel, p. 305). Additionally, homosexual men identified higher body dissatisfaction and great occurrence of bulimic and anorexic symptoms in this study. It is important to note that this study did not acknowledge particular subcultures within the gay community, which may have had an effect on the results of this study.
Traditionally, psychologists thought that the connection between homosexuality in men and the manifestation of anorexia nervosa was a result of the conception that homosexual men had a greater identification with feminine characteristics. This theory supports the social assumption that anorexia nervosa is still a female-specific disorder, only occurring as a result of feminine identification. This study concludes that an increased identification with femininity is not the reason for this link between homosexuality and body dissatisfaction (Russel & Keel, 2002). Rather, these results suggest that homosexual men struggle with unique social expectations that are unrelated to feminine issues, contributing to the occurrence of anorexia nervosa in this population.
Ellen Shor-Haimoff and Regina Hausler found that young men who are still uncertain about their sexual identity are particularly susceptible to disordered eating behaviors (Blotcher, 1998). Men with mixed feelings about their sexuality, in addition to harboring an eating disorder, exhibited extremely low self-esteem. Interestingly, the men that Shor-Haimoff and Hausler treated were body builders, models, dancers, and wrestlers. Shor-Haimoff says that these men suffered from the same societal restrictions usually placed upon women in terms of maintaining a perfect body. Another psychologist, Steven Levenkron (to whom Karen Carpenter went for treatment of her eating disorder), says that there is no difference in the actual disorder between heterosexual and homosexual men (Blotcher). However, he asserts that the pressures of accepting one's homosexual identity can facilitate the development of an eating disorder. Fears about telling family and friends about one's homosexuality parallel the fears a man faces when deciding whether he should come forward about his eating disorder. A man with anorexia nervosa is made to feel ashamed by his eating disorder, much the same way a homosexual man is made to feel inadequate because of his sexuality.
Athletes are members of another at-risk group for anorexia nervosa. Particularly, endurance sports like running, wrestling, swimming, gymnastics, and other sports that encourage lean body types are most vulnerable to disordered eating behavior (Ray, 2004). These sports often have weight classifications, an emphasis on body appearance, and/or low body fat percentage preferences, putting pressure on young men to conform to these standards in order to secure success. Previous investigations have concluded that participation in these sports can be detrimental to the body perceptions of young women, but young male athletes are beginning to be seen as more susceptible to the pressures of athletic demands. Additionally, anorexic males are more likely to be "pre-morbidly athletic" than females, suggesting that psychologists may need to give more attention to eating disorders in male athletes (Muise et al., 2003). Angie Hulley, a researcher at the University of Leeds in Great Britain, states:
We have assumed there is less of a problem among male athletes only because there is less evidence that it exists. But they are prone to the same performance pressures as women and it is just as easy for them to get caught up in the mindset that you need to be thin to win. (Bee, 2004, July 13, p. 3)
Think about it: High school wrestlers at the top of their game literally starve themselves or exercise in layers of clothing in order to satisfy weight class requirements. If they reach their goal, they are praised and are "allowed" to eat by their coaches. If they fail, they must keep trying.
The emphasis on athletic achievement for young men reinforces why compulsive exercise is also a typical symptom among young men who suffer from anorexia nervosa as a way of losing weight, rather than food restriction (Drummond, 2002). Young men see dieting by means of food restriction as a feminine technique to lose weight. Enduring physical pain is seen as a typical practice of claiming one's masculinity, so it is understandable why these young athletes can easily turn exercise into a compulsive behavior. Consequently, most young men who use exercise to lose weight do not see it as a legitimate dieting technique, but as a "normal" part of asserting their masculinity (Drummond).
In addition, athletic coaches encourage these maladaptive practices as "normal" ways of losing weight and achieving athletic success. As a result, the athletes have turned these reinforced habits into internalized distorted beliefs that their destructive behaviors will help them succeed. Moreover, a successful athlete achieves high status among his peers, thus reinforcing the importance of hierarchical masculinities in society (Drummond, 2002). However, the side effects of anorexia actually serve to weaken an athlete and his performance suffers (Ray, 2004). In fact, Bruce Hamilton, an athletics expert for the British Olympic team, says that "inadequate dietary intake will mean all body systems are compromised" (Bee, 2004, July 13, p. 3). Athletes who practice eating disordered behaviors are more likely to suffer from stress fractures, loss of muscle mass, and infections (Bee). Their bodies are breaking down.
Expanding Upon a Past Investigations for Clinical Treatment
In 1999, Cindy Crosscope-Happel investigated the world of men suffering from anorexia nervosa in an exploratory study that centered on distinguishing characteristics of the disorder in males and addressed the gender discrepancy in eating disorder diagnostic criteria. Her paper focused on identifying clinical characteristics in order to develop a measure that would help clinicians assess patients for possible risk factors associated with the disorder. As a result, this measure could contribute to the future effective treatment of anorexia nervosa in male clients (Crosscope-Happel).
The researcher acknowledges this development in the understanding of anorexia nervosa in males and sees the value of such an accomplishment. The Assessment of Male Anorexia Nervosa (Crosscope-Happel, 1999) details many characteristics of the disorder, specific to the male population, which the current study also addresses. However, Crosscope-Happel does not reach into social issues of gender and masculinity to the depths that are needed, considering the increased emphasis on male body image and affirmations of masculinity based on society's expectations for "proper" boys and men. While Crosscope-Happel's contributions to this area of mental health are very significant, it is important that researchers and clinicians go beyond the clinical characteristics and address issues of masculinity and how they relate to the development of anorexia nervosa in men.
Filling in the Gaps:
Integrating Masculinity Education with Feminist Concepts of Empowerment and Acceptance
In "The Politics of Changing Men," R. W. Connell (1996) addresses a form of therapy known as "masculinity therapy," which is "the best-known form of gender politics among men at present" and is often referred to as "the men's movement" (see section "Masculinity Politics"). Here, I find it important to distinguish the current proposal for acknowledging masculinity in a feminist environment from this concept of "masculinity therapy." Masculinity therapy, as detailed in Connell's article, derives itself from Men's Liberation and actually ignores social issues, acting mainly as a way to address "the pain heterosexual men feel and their uncertainties about gender" (see section "Masculinity Politics"). Additionally, the theorists of this kind of therapy feel that men are "unfairly blamed by feminists" and "are more disadvantaged than women" (see section "Masculinity Politics").
The current proposal is not meant to support this kind of approach. Male anorexics suffer from the same clinical disorder as female anorexics but endure some differing surrounding characteristics, based on their gender and socialization within that gender. The emphasis on acknowledging masculinity's role in a male anorexic's life is proposed in order to be sure that all areas of the mental disorder are considered, both clinical and emotional. Masculinity politics looks to switch the focus of suffering from women to men (Connell, 1996). Acknowledging masculinity in a feminist environment serves to address the different struggles that men and women face as related to eating disorders, not that one gender is worse off than another. It is important that clinicians understand this treatment proposal as a move to include men who suffer from anorexia nervosa in order to better treat them.
First, a new approach to treatment must focus on guiding these young men through healthy development of self-perception and body image that acknowledges their emotional, psychological, social, and cultural needs. Further, psychologists must confront the major gender-bias in the diagnostic criteria for anorexia nervosa, as outlined in the DSM-IV. Obviously, the fourth criterion regarding amenorrhea does not apply to the male population. However, men do experience diminished levels of testosterone and lowered sexual desire. Some psychologists have suggested these symptoms may be possible corresponding features for this final criterion (Crosscope-Happel, Hutchins, Getz, & Hayes, 2000). Acknowledging these physiological signs of the effects of starvation on the male body is critical. Including these features in future revisions of diagnostic materials for anorexia nervosa can allow for an increase in awareness of the disorder as a legitimate problem for both genders. Arnold Andersen (1990), one of the primary experts on male anorexia nervosa, stated: "The diagnosis of males with eating disorders is usually a straightforward process, but first you have to think of it as a possibility" (p. 133).
Each factor of male anorexia nervosa should be addressed with relationship to the current social constructs of masculinity, keeping in mind that there may not necessarily be one "right way" to be a man. Living by the limiting, hypermasculine rules society places on men is damaging to a majority of men in society because very few men actually satisfy the criteria to be considered this impossibly perfect man. Few men actually achieve the hypermasculine ideal. However, the majority of men strive to compete with one another because that is how young boys are raised. Ultimately, almost all men will "fail" in one way or another, whether this failure is related to the workplace, sexuality, or physique. Hierarchical masculinity is much of the reason why men internalize social and cultural pressures and turn these demands into emotional and psychological problems associated with anorexia nervosa.
Stories of many young boys in therapy make it clear that we need a better understanding of their complex, unique world. Today, feminist psychologists frequently incorporate education about the oppressions women face within society when treating girls who suffer from anorexia nervosa. However, Western culture also oppresses boys by denying them freedom of emotional expression, except anger. This denial of a wide range of emotions is exhibited in Eric, one young man journeying toward recovery from an eating disorder:
Interviewer: Do you ever want to cry?
Eric: Maybe I want to once in a while, but I'm not a little kid any more.
Interviewer: Meaning only little kids cry?
Eric: Well, little kids and girls--women, you know. I mean, my mom cries sometimes, my little sister cries a lot. (Rabinor, 2002, p. 120)
Judith Rabinor (2002), Eric's psychotherapist, asserts that her patient is merely abiding by one of the traditional expectations of masculinity; a boy should "never cry." Eric goes on to say that his father is a real man because "he would never cry. He really deals with stuff, ya know? Never lets it faze him" (p. 120). Eric does not feel that he can express his feelings, so he expresses them through the control he exerts on his body through his eating disorder. His eating disorder is a way for him to speak out; much the way feminist psychotherapy characterizes symptoms in an eating disordered girl as her speech. By educating these young men about social issues related to their masculinity, psychologists can begin to empower their patients to take charge of their bodies and no longer submit to the struggle of achieving impossible perfection.
As children, much of what we learn is obtained from the people in our family. It is telling that Eric learned this concept of holding his emotions in from his father. Expressing these emotions would be shameful for him as a young man (Rabinor, 2002). Young men internalize social expectations of masculinity from a very early age, usually as a result of their family environments. Families who emphasize traditional roles of masculinity must be assessed in addition to considering families that place strong value on appearance when treating cases of male anorexia nervosa.
Aside from the family, the limitations society places on boys can contribute to the maintenance of anorexia nervosa. Society constructs standards of masculinity and femininity by attributing various features of human behavior to one gender or the other. A main quality of masculinity is competition. Psychologists find that male anorexics use their disorder as a form of competition. According to Drummond (2002), the men in his study exhibited competitive qualities in their eating disorders, by competing to be the "best eating-disordered male." One man was "just aiming to be the sickest guy there" (see section "Eating Disorders as a Form of Competition"). Competition within male anorexia nervosa is also about competing with oneself: "It may be physically doing the most astonishing feats with one's body such as holding food in one's gullet for long periods of time and then vomiting hours later" (Drummond). Therapists need to address this competitive tendency among male anorexics as a crucial factor in the maintenance and progression of anorexia nervosa in this population.
Drummond (2002) also considered the concept of a cultural shift in how men perceive their bodies. Much the way feminist psychotherapy has addressed the female body in the public arena, this new approach must look at the male body in this context and how this ideal image affects some young men. Many of the men in Drummond's study have internalized an intense fear of fat, both on their body and that which they eat. Fat is also linked to unhappiness (Drummond). For example, one man stated:
I suppose I just made the connection between eating and fatness. But the change was more when something clicked like, "If you don't eat, you will lose weight." And if you lose weight you will be happier with what you see in the mirror. Then you will be happier person. (Drummond, see section "Fat Phobia")
This connection between positive self-esteem and thinness is common among men with anorexia nervosa. These obsessions with thinness and fat are affecting men with increased intensity and need to be addressed in the therapeutic environment. A new treatment approach for male anorexia nervosa may benefit from a special focus on media images of male bodies and how these images create oppressive and impossible expectations for young men.
The age of the average anorexic male is also important to consider in terms of masculinity development and social influence. The average age of onset for anorexia in young men is 17.1 years old (Muise et al., 2003). Young men at this age are reaching the end of puberty, embarking on adulthood, and beginning to make major life decisions about education, career, and family. Add in the pressure many young men face to be successful, strong, "sturdy oaks," one would expect psychologists to find their couches laden with boys at their breaking points. Instead, many young men choose to deny these feelings of pressure and inadequacy and turn the frustration in on themselves. If their lives are spinning out of control, at least they can keep their bodies in check through their eating disorders. Young men need to be taught that they do not have to strain themselves to live up to these impossible ideals of the ideal man. The ideal man is not real. He is a social construction that is impossible for a human being, with faults, difficulties, struggles, and emotions, to truly achieve. Instead, a therapist must emphasize to a young man in therapy that, at this crucial point in his life, he is entitled to be emotional and to ask for help; acceptance is critical. A therapist treating a male anorexic patient must assure him that these behaviors will not make him "less of a man"; his eating disorder does not make him "less of a man."
More unique features exist that are vital to gaining a clear understanding of anorexia nervosa in males as a disorder that is manipulated by social and cultural expectations of the male body and masculinity. These pressures can lead to emotional and psychological problems that are exclusive to the male anorexic and require specific attention. Psychologists should pay attention to the following key points when developing a treatment approach for anorexia nervosa in males that considers the effects of social influence:
1. Male anorexics tend to feel they should be ashamed of their problems because society has always seen anorexia nervosa as a "female" problem. These men may feel isolated and turn their frustrations inward in the form of an eating disorder. An anorexic's isolation is his safe place. Bringing him into an accepting therapeutic environment is essential to an anorexic's self-acceptance and critical to developing a sense of belonging in a society that isolates him for being different.
2. Psychologists should consider the increase in the display of male bodies in the media, the shape of these bodies, and how these concepts relate to the internalized expectations of young men for their own bodies, as found in various research studies.
3. The family of a male anorexic patient must be included in the treatment in some way, in order to continue the awareness of masculinity issues and body image concerns as legitimate problems for young men. Families are a primary source for a support network and validation from his family can play a major role in the recovery of an anorexic.
4. Homosexual men and athletes are two possible risk groups for anorexia nervosa in men, mainly due to the emphasized social pressures these groups face concerning body image, weight classification, and appearance.
5. Many young men who develop anorexia nervosa have unique pre-morbid circumstances (such as being overweight prior to their disorder), which differentiate them from female anorexics and can greatly affect the way anorexia nervosa is expressed in the male patient.
6. Environmental characteristics within the client-therapist relationship of feminist psychotherapy, such as empowerment and acceptance, should be implemented in a male-focused, psychosocial treatment of anorexia nervosa. Future developments will benefit from close examination of feminist psychotherapy, the only other gender-specific treatment approach to this disorder.
7. In conclusion, male anorexia nervosa is a problem in Western culture that must be addressed before it becomes an out-of-control epidemic for young men. Western culture raises its boys to be ashamed of acting in any way that does not conform to its standards of masculinity. Society has always seen anorexia nervosa as a "female problem" and thus, young men who suffer from this debilitating disorder are ignored, isolated, and insufficiently treated. Psychologists must challenge this ignorance within the current feminist therapeutic community in order to begin breaking down the stereotype of anorexia nervosa as a strictly "female problem" so that young men will no longer suffer starvation in silence.
The College of New Jersey
Correspondence concerning this article should be addressed to Catherine Soban, Women's and Gender Studies Department, The College of New Jersey, 2000 Pennington Road, Ewing, NJ 08628. Electronic mail: email@example.com
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Catherine Soban, Women's and Gender Studies Department, The College of New Jersey. This undergraduate thesis was written for my Women's and Gender Studies Senior Seminar: Methods and Theory while pursuing a Bachelor of Arts degree in Psychology and Women's and Gender Studies at The College of New Jersey in Ewing, NJ. I would like to thank Ellen Friedman, Ph.D., for her continued guidance during the writing and editing of this paper, as well as the Women's and Gender Studies Department and my fellow graduates for their support throughout this process.
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|Publication:||International Journal of Men's Health|
|Date:||Sep 22, 2006|
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