Course:SOWK551/2021/Strategies for Improving Inclusivity and Outcomes for Male Identified Patients in Eating Disorder Treatment Programs
Literature review synthesizes gender specific challenges, as well as clinically recommended adaptations for treating eating disorders in male identified populations.
Eating disorders are a set of maladaptive coping mechanisms and unfortunately, no demographic is immune. Despite this reality, eating disorders have traditionally been categorized as a uniquely female illness and as such, treatment literature, research samples, and assessment tools have largely been feminized. Within this societal context, male identified patients get lost among the stereotypes of eating disorders. As such, men end up presenting in health care with more severe symptoms, and are more frequently underdiagnosed and undertreated (Kinnaird et al., 2019). Furthermore, male identified patients face a range of gender specific challenges to seeking and receiving care for their eating disorder.
This literature review synthesizes gender specific challenges, as well as clinically recommended adaptations for treating eating disorders in male identified populations as found in recently published academic literature. The information collected here is intended to guide social workers to progress toward using best practices for care as defined by patients themselves. To keep the content current, only peer reviewed journals within the last 10 years have been included. With regards to male identified patients receiving treatment for eating disorders in health care settings, the following search terms were used to focus and refine the search: “experiences”, “challenges”, “treatment”, “adaptations”, and “inclusion”/ ”inclusivity”. A gender informed context of eating disorders will be presented, followed by treatment adaptations and implications for the social workers in health care settings.
As this paper aims to address the invisibility of men with eating disorders, it cannot go unstated that the context of this research takes place against the backdrop of a deeply patriarchal society that has classically ignored, denied, and invalidated the health concerns of women. This research also takes place in a traditionally binary society which has also long ignored, or victimized trans and non-binary patients within health care. Marginalized gender identities and structurally oppressed demographics must not be forgotten as health care advances. With these acknowledgments, I recognize that dignified and equitable access to health care must be guaranteed for all people, and health care will not be considered just or reputable until this is consistently delivered. For the sake of depth of the topic within the parameters of this assignment, solely the experiences of men/male identified populations will be discussed today.
Gendered Context of Eating Disorders in Male Identified Patients
While it was believed that men made up 10% of people with eating disorders, male identified patients are now being recorded as an underreported 25-40% of the population (Strother et al., 2012). With the increase in diagnoses, comes the realization that men with eating disorders have been long misunderstood and underserved by health care (Collier, 2013a; Strother et al., 2012). Bunnell (2016) recognizes that in the same way that gender and body image ideals influence women, men too were being impacted. However, because men are impacted by the culture of masculinity, the disorder manifests uniquely, making it an invisible to those who only understand eating disorders as a female illness (Bunnell, 2016; Tchanturia et al., 2018; Strother et al., 2012).
Research reveals that men experience unique symptom presentation within eating disorders, and gender specific challenges associated with getting help (Bomben et al., 2022; Kinnaird et al., 2018). While eating disorders are generally characterized by a fixation on body image, self-worth, and subsistence rituals for all, men with eating disorders tend to focus less on thinness and weight loss, and focus more on muscularity, weight gain, and lean fitness (Bunnell, 2016; Collier, 2013b; Strother et al., 2012). Eating disorder behaviours in men also trend away from purging and more toward excessive exercise (Collier, 2013a). Because the focus on fitness and weight gain does not fit into societal stereotypes of eating disorders, this symptom presentation is less likely to trigger a diagnosis or signal the need for an intervention (Bunnell, 2016; Kinnaird et al., 2019). One of the loudest themes echoed in the literature is that men experience delayed recognition of their eating disorder, or have their symptoms denied altogether (Bomben et al., 2022; Richardson & Paslakis, 2021).
Statistics present a story of delayed onset, increased likelihood of being previously overweight, and greater psychiatric comorbidities in men with eating disorders (Kinnaird et al., 2019). Studies also show that while most men with eating disorders identify as heterosexual, there is a sharp increase of gay men being diagnosed with eating disorders (Collier, 2013a; Strother et al., 2012). While this is true statistically, Strother et al. (2012) clarify that not all gay subcultures stress body image, and as such, homosexuality is not a predictive factor for eating disorders. In the same vein is the recognition that while there are statistical trends in eating disorder presentation among men, not all men have a singular or unified experience of eating disorders. Treatment that considers their distinctiveness as well as their individuality is needed (Downs & Mycock, 2022).
Four essential assessment adaptations named when working with male populations are to examine: the nature of binge eating, muscle dysmorphia, body dissatisfaction, and disordered eating – as they relate to the culture of masculinity each individual is influenced by (Bunnell, 2016). Clinicians should also be prepared to inquire how men consume, experience, and respond to cultural messaging around masculinity (Bunnell, 2016). For men in particular, depression and shame could be hidden through emotional repression, and therefore substance use and prior sexual abuse history can be explored as potential concealed contributing factors (Strother et al., 2012).
Challenges Faced When Seeking Help
Studies recognize that men with eating disorders face the added challenge of being conditioned by masculinity to hide and repress their feelings (Collier, 2013b). Because eating disorders are so inherently emotion based, emotional repression is not only a contributing factor for the illness, but also an obstacle to reaching out for help when it is needed (Collier, 2013b; Tchanturia et al., 2018). Further influenced by conventional masculinity, the feminization of services and information can lead to further internalized stigma, shame, and lack of access to relevant information about eating disorders (Bomben et al., 2022;Downs & Mycock, 2022; Richardson & Paslakis, 2021). When men do reach out for help, we heard from them that they were at risk of clinician judgments hindering timely or accurate diagnoses, treatment opportunities, and treatment outcomes (Richardson & Paslakis, 2021; Strother et al., 2012).
Within treatment programs, men reported feeling alienated in female dominated treatment programs, excluded in female dominated dialogue during group therapy, and not relating to feminized services or spaces where services are provided (Collier, 2013b; Kinnaird et al., 2019; Richardsom & Paslakis, 2021). Men also report being perceptibly impacted by gendered biases coming from practitioners who reinforce masculinity norms (Bunnell, 2016). Overall, outdated beliefs around who experiences eating disorders and what the illness looks like are preventing men from seeking help, and preventing clinicians from providing effective, and optimal treatment (Downs & Mycock, 2022).
General challenges that have been highlighted for men in treatment have been: overly high expectations of treatment programs to cure them, coupled with a negative view on therapy processes as a whole, ambivalence toward recovery, and difficulty letting go of the eating disorder advantages and coping with perceived negative outcomes of recovery (Richardson & Paslakis, 2021).
Treatment Adaptations for Men with Eating Disorders
While adaptations for men remain underexplored, male patient perspectives on the issue are increasingly being sought (Kinnaird et al., 2019). Downs & Mycock (2022) suggest that because current treatment for eating disorders are only moderately effective at best, developing gender informed treatment is crucial for populations to have an optimal chance at recovery. There are two schools of thought regarding adapting treatment for male populations. On one hand, advocates suggest developing programming in a way that speaks directly to the male experience, societal influences, and medical needs (Downs & Mycock, 2022; Thapliyal et al., 2018). Research also reflects suggestions to a move away from a gender centred approach, stating that programming should equally accommodate the ways the disorder presents across a diverse range of cultural groups (Downs & Mycock, 2022).
Either way, research is revealing that most men clearly state that they don’t necessarily require new interventions, but prefer a person-centred approach that treats them as individuals and not as representatives of their gender or sexual orientation (Collier, 2013b; Kinnaird et al., 2019). Male patients are cited stating that they feel typical treatment frameworks would be suitable for them if modifications to the literature, environment, and dialogue in programs were made to acknowledge the cultural context of their experience (Kinnaird, 2019; Tchanturia, K. et al., 2018). We hear from men that even within treatment programs for male, they would like to be seen as individuals because there exists a vast range of how men experience eating disorders within masculine subcultures (Kinnaird et al., 2019).
All of the literature spoke to the urgency of dispelling myths, stereotypes, and refining discourse and education around eating disorders in society as a whole. Bomben et al. (2022), suggested that efforts be focused on portraying diversity in eating disorder identities across social media, health care, and education settings. Kinnaird et al. (2019), speak to the need to broaden eating disorder treatment materials to be more gender neutral and accessible. In program settings, men requested the physical environments, décor be made more gender neutral as well (Kinnaird et al., 2019). Essentially, a cultural shift needs to take place on the whole, and this shift needs to trickle down into the lived experience of diverse eating disorder patients.
Application for Social Work in Health Care Settings
Clinicians have little experience with the unique male presentation of eating disorders (Collier, 2013b). Improved clinician training was a distinct group of suggestions that was reflected in multiple studies and a wealth of insight into potential clinician improvement has been documented (Bunnell, 2016; Downs & Mycock, 2022; Tchanturia et al., 2018).
First and foremost, clinicians need to develop ways of speaking that acknowledge differences in contributing factors, symptom presentation, and treatment styles for all individuals rather than focusing on gender/sex identities (Collier, 2013b; Richardson & Paslakis, 2021). In that vein, therapists/clinicians/health care providers can utilize an awareness of gender influences to improve their quality of care, without needing to segregate genders or create brand new intervention tools (Bunnell, 2016).
Clinician’s internal beliefs – explicit or implicit – about masculinity, will invariably impact the way they assess, engage, and treat male patients with eating disorders (Bunnell, 2016). Some of these views may manifest in working with male patients with eating disorders by expecting men to be less emotionally sophisticated by women, viewing men as less masculine for having an eating disorder, and praising men for eating disorder behaviours like excessive exercise and over-prioritizing fitness (Bunnell, 2016; Downs & Mycock, 2022). Bunnell (2016) stresses the significance of clinician’s responsibility to self-monitor for embodied gender biases, or stereotype affirming views that clients could experience through countertransference. Monitoring closely for gendered flavours of countertransference is essential to mitigate the subtle endorsement of acculturated beliefs during the treatment process (Bunnell, 2016). Bunnell (2016) suggests that health care providers can test for internal biases by identifying with intentional precision the ways they interact differently with each demographic of people with eating disorders.
While targeted research is needed to better serve men with eating disorders, there is enough known to begin program re-design and clinician training. The insights gathered from this literature review can be used directly by social workers who work with patients with eating disorders to make their services more patient centered, gender informed, and effective for the affected populations. Gender informed care is necessary to optimally support male identified patients with eating disorders to transcend gender specific obstacles to recovery, while creating gender specific treatment interventions may not be necessary at this time. In other words, a person-centered approach has been highlighted profusely as the next step in the evolution of eating disorder approaches. As services evolve and move forward, male identified patients also need to be valued and consulted as stakeholders in the future of their care (Downs & Mycock, 2022; Richardson & Paslakis, 2021).
Bomben, R., Robertson, N., & Allan, S. (2022). Barriers to help-seeking for eating disorders in men: A mixed-methods systematic review. Psychology of Men & Masculinities, 23(2), 183-196. https://doi.org/10.1037/men0000382
Bunnell, D. W. (2016). Gender socialization, countertransference and the treatment of men with eating disorders. Clinical Social Work Journal, 44(1), 99-104.
Collier, R. (2013a). Gender perceptions on eating disorders slow to change. CMAJ 185 (3) E151-E152; DOI: https://doi.org/10.1503/cmaj.109-4360
Collier, R. (2013b). Treatment challenges for men with eating disorders. CMAJ February 19, 2013 185 (3) E137-E138; DOI: https://doi.org/10.1503/cmaj.109-4363
Downs J, Mycock G (2022). Eating disorders in men: limited models of diagnosis and treatment are failing patients. BMJ; 376-537. doi: 10.1136/bmj.o537. PMID: 35232721.
Kinnaird, E., Norton, C., Pimblett, C. (2019). “There’s nothing there for guys”. Do men with eating disorders want treatment adaptations? A qualitative study. Eating and Weight Disorders 24, 845–852. https://doi.org/10.1007/s40519-019-00770-0
Richardson, C., & Paslakis, G. (2021). Men’s experiences of eating disorder treatment: A qualitative systematic review of men‐only studies. Journal of Psychiatric and Mental Health Nursing, 28(2), 237-250. https://doi.org/10.1111/jpm.12670
Strother, E., Lemberg, R., Stanford, S. C., & Turberville, D. (2012). Eating disorders in men: underdiagnosed, undertreated, and misunderstood. Eating disorders, 20(5), 346-355.
Thapliyal, P., Hay, P., & Conti, J. (2018). Role of gender in the treatment experiences of people with an eating disorder: a metasynthesis. Journal of eating disorders, 6, 18. https://doi.org/10.1186/s40337-018-0207-1
Tchanturia, K., Kinnaird, E., Norton, C., (2018). Clinicians’ views on treatment adaptations for men with eating disorders: A qualitative study. BMJ Open, 8(8), e021934-e021934. https://doi.org/10.1136/bmjopen-2018-021934