Abstract
This study aimed to explore experiences of men currently using eating disorder services. Eight men from two eating disorder services were interviewed about their experiences of seeking and receiving treatment. Two superordinate themes emerged from Interpretative Phenomenological Analysis: (1) difficulty seeing self as having an eating disorder; and (2) experiences of treatment: how important is gender? The underlying themes varied in their specificity to men, with some echoing findings from the female eating disorder literature. Difficulty admitting the eating disorder may link with eating disorder psychopathology as well as gender-specific issues. Implications for clinical practice and future research are discussed.
Introduction
Despite Morton’s (1694) early description of a 16-year-old boy with an eating disorder (ED), EDs are often assumed to be a female phenomenon and males with EDs are often ‘overlooked, understudied and underreported’ (Greenberg and Schoen, 2008: 464). Males represent 10% of clinical ED cases (Muise et al., 2003) yet have only relatively recently received more research attention.
Treatment approaches are often based on interventions developed for women with EDs and there are no male-specific treatment guidelines (National Institute for Health and Clinical Excellence, 2004). While treatment in predominantly female environments can be successful for males (Woodside and Kaplan, 1994), issues of stigmatization and isolation have also been reported (Andersen and Holman, 1997; Weltzin et al., 2005). Males may have unique needs, including consideration of masculine identity, gender role conflict and emasculation (Fernández-Aranda et al., 2009; Greenberg and Schoen, 2008).
Increasing recognition of the value of the accounts of people with EDs has led to a number of qualitative studies using female samples, highlighting ambivalence about change (Nordbø et al., 2008), positive and negative functions of EDs (Serpell et al., 1999), role of control (Patching and Lawler, 2009; Reid et al., 2008), and impact of ED on identity (Malson et al., 2004). Participants understood their ED to have developed due to weight-related or interpersonal factors (Nevonen and Broberg, 2000) and identified the importance of feeling cared for by staff (Reid et al., 2008). Barriers to accessing treatment were reported to be fear of stigma, shame, fear (and cost of) change and poor knowledge about EDs (Hepworth and Paxton, 2007).
To date, only a handful of qualitative studies have reported men’s views on having an ED (Copperman, 2000; Drummond, 1999, 2002). Drummond’s articles used an ‘inductive approach’ to draw themes from interviews with eight Australian men. Drummond (2002) described three themes: (1) EDs as a form of competition; (2) fat phobia – a cultural shift in men’s perception of male bodies; (3) fitting the image – a flawed sense of masculinity. Drummond (1999) also reported three themes: (1) EDs as a form of masculine identity; (2) fear and loathing of fat; (3) treatment. The Eating Disorders Association (EDA; now beat) asked nine British men about the accessibility and acceptability of ED services through semi-structured telephone interviews (Copperman, 2000). Descriptive results reported men’s difficulty discussing EDs with peers, lack of recognition of the ED by GPs, and the importance of support from family, friends and professionals to access services. Having contact with other men with EDs was seen as more important than gender of professional. The studies supplied interview schedules and cited verbatim quotes from participants, providing valuable insight into their experiences. Recruitment was through voluntary agencies and there was no assessment of participants’ ED status. It appears that both Drummond articles described the same participants but the overall theme structure was unclear and there was a lack of demographic information with which to situate the sample. The EDA study provided extensive demographic information but no data analysis.
The majority of research into EDs in men has been quantitative, investigating gender differences in ED psychopathology as well as treatment outcome for men with EDs. Findings are mixed about whether gender differences exist in ED symptomatology, such as compensatory behaviours (Button et al., 2008; Crisp, 2006; Freeman, 2005; Muise et al., 2003; Weltzin et al., 2005) and any differences appear to be subtle. For example Meyer et al. (2005) found bulimic psychopathology was associated with anger suppression in women but with state anger in men, suggesting a different function of bulimic behaviours depending on gender. Several risk factors for men developing EDs have been identified: (1) avoiding teasing for being overweight; (2) avoiding weight-related illnesses; (3) improving gay relationships; and (4) participation in sports where weight control is needed to improve performance (Andersen and Holman, 1997). The literature remains divided whether homosexuality is associated with EDs in men (Bramon-Bosch et al., 2000; Carlat et al., 1997; Olivardia et al., 1995).
Although such research contributes to understanding EDs in men, many of the studies are limited by the use of measures designed for women with EDs and diagnostic criteria that have been developed using females with EDs. Much of the research extrapolates from previous research with female ED sufferers, both in terms of research questions and interpretation of results, which assumes that the experiences of men and women with EDs are similar. To date, no study has researched the views of men receiving treatment from an ED service. The few qualitative studies that exist have raised issues for further exploration but, as they were recruited via self-help organizations, their experiences may not be transferable to men who are receiving specialist treatment. With little contextual information from the qualitative studies, it is unclear whether participants were similar or different to men who present to specialist services.
There is a need for additional, methodologically rigorous qualitative research, to learn more about what men want from ED treatment, what they have found helpful, what has made it difficult to seek help and the impact of the issue of gender in treatment, as viewed by the men themselves. This study aims to address the following questions:
What is it like for men to live with an ED?
What is it like for men to seek treatment for an ED?
What is it like for men to receive treatment for an ED?
Method
Participants and sampling
Following NHS ethics approval and Research and Developmental authorization from the Trusts involved, participants were recruited from two specialist ED services in London, UK. They were sampled purposively to ensure they had experience of having an ED and receiving treatment. Initial approach was via their clinician. If interested, the men were telephoned by the first author (KR) and interviews were arranged. Inclusion criteria were adult men currently receiving inpatient, day patient or outpatient treatment at either of the two services. Exclusion criteria were being too physically or psychologically unstable to participate (as assessed by clinical staff) or requiring an interpreter for the interview to be conducted in English.
Sixteen men were approached and eight men agreed to participate: three with anorexic presentations (AN or eating disorder not otherwise specified (EDNOS), AN subtype), five with bulimic presentations (BN or EDNOS-BN). Of the eight men who declined to participate, three stated that they might like to participate at a later date and the remaining five said they were not interested.
All participants were white British or white Irish. One participant was married, one was separated and six were single. One man identified his sexuality as homosexual, the remaining as heterosexual. Mean age was 38 (range 24–56 years) and mean illness duration was 13 years (range four to 34 years). All participants reported having one or more comorbid difficulties including depression, obsessive compulsive disorder, body dysmorphic disorder, post-traumatic stress disorder and alcohol dependence. Depression was the most common co-morbid problem, being reported by half the sample. For half of the sample, this was their first treatment experience. Of the half who had had previous treatment, only one had had inpatient treatment. All were currently receiving outpatient treatment at the ED services: seven were having individual therapy, one was having group therapy.
Interview procedures
A semi-structured interview schedule was developed from a review of the existing literature. Broad topics included background information about the participant; the development and history of the ED; experiences of health and mental health services; and the impact of the ED on self and systems around the individual. The interview schedule served as a guide but questions evolved from interviewees’ responses. A male inpatient with anorexia read the interview schedule and commented on acceptability of topic areas.
KR conducted the interviews which lasted approximately 60–90 minutes and took place at the participants’ treatment base. The interviews were audio-taped, transcribed, then identifying information was removed from the transcripts. All names used are pseudonyms.
Data analysis
The interview transcripts were analysed by KR using the IPA technique described by Smith et al. (2009). Analysis of each transcript was in the first instance descriptive to summarize the participant’s feelings and concerns. The data were then analysed again in an interpretative fashion, positioning the initial descriptions in a wider context and thinking about what it meant for the participant to have said what they had said (Larkin et al., 2006). Emergent themes were identified from each participant’s transcript. Then themes were integrated across participants to identify shared themes and pulled together to form a meaningful summary.
Attempts were made to maximize the reliability (trustworthiness of the data) and validity (trustworthiness of the interpretations) of the research (Stiles, 1993). The analysis process was independently audited by DS, who assessed the coherence of the chain of evidence from interview transcripts to the final superordinate themes (Smith et al., 2009). Additional techniques employed to enhance the quality of the analysis were reflexive journaling, acknowledgement of researcher perspective and provision of evidence (extracts from transcripts) to support interpretations (Whittemore et al., 2001).
Results
The main research aim was to explore the experiences of men with EDs and two superordinate themes emerged relating to this aim: Difficulty seeing self as having an ED and Experiences of treatment: how important is gender? Each of the superordinate themes consists of a number of themes (shown in Table 1). The themes are shared by a minimum of three participants, although the majority are shared by at least 50% of participants. Extracts from participants’ transcripts are provided to illustrate the themes.
Theme and superordinate theme structure
Difficulty seeing self as having an ED
Some participants identified that the biggest challenge they had faced was admitting they had an ED and that it was a problem. Admitting the existence of the ED was an ongoing process and participants varied in their acknowledgement that the ED was a problem. Following the initial difficulty of admitting to oneself, they then faced the challenge of disclosing the problem to others.
Difficulty admitting ED
Participants found it difficult to admit to themselves and to others that they had an ED. Many described this as the biggest challenge they have faced:
It was pretty tough admitting it to myself, and then admitting it to my parents, I think the rest of it was quite easy after that. (Greg) Um … [pause] it took a lot for me to admit it. It took over 10 years for me to do it. (. . .) I think I was just a bit ashamed on the admitting side. And going for help, was just because I thought I was being ridiculous. (Ed)
Some were aware that their eating behaviour was not ‘normal’ but it was hard to see it as a problem and take it seriously. Some were still unable to admit or accept how big a problem the ED was: ‘I knew at the time that I probably did have some kind of disorder with my eating, because being sick isn’t normal. But I’d always discount those kind of things’ (Ed).
Psychoeducation about the impact of the ED on health was effective in helping them to admit their eating was a problem. The more they understood about the ED, the more they realized the seriousness of the ED and the more they were able to admit that they had a problem:
I’d been given all this stuff to read, been told all this information and things, it’s more serious than I thought, it’s more of a problem than I thought it was. So from that point on, I was quite keen to get it sorted out. (Henry)
Once they had admitted that the ED was a problem, they wanted treatment and for the problem to be sorted out. Many were proactive about seeking help to make sure they got what they needed. Having asked for help, they found the long waiting list wait difficult:
(I) did a little bit of research, at least if you go in to see him (GP) with a suggestion, he’ll push it through. It’s very difficult for him at times to come up with an initiative himself because he doesn’t … he may not understand the problem then doesn’t know where to look. (Dave)
Men with EDs are invisible
Participants felt that EDs are thought of by society as a female issue, something that only happens to women. They felt there is a lack of visibility of male EDs in the media:
What they see in the papers is young girls trying to get themselves down to size zero. Do you ever read about men trying to do that? I don’t. It just doesn’t get a mention. There’s no visibility there. (Dave) Most people are more socially aware than to say ‘but you’re male’ but a lot of people are surprised if you, you know, if you are male with an eating disorder … even if they don’t say so. (Frank)
Participants also felt that there is a stereotyped view of people with EDs as being women and that people fit into neat boxes of anorexia or bulimia. Participants felt alone as a man with an ED, as if they were the only ones. Some questioned if there was something wrong with them for them to have an ED as a man:
I felt ‘I’m the only guy in the world this has happened to’. So it can be quite an isolating thought as well ‘and no other guys have had this problem. What’s wrong with me? Why have I succumbed to this if no-one else has?’ (Henry)
There was a sense that this makes the ED even harder to talk about than it already is. The idea that only women get EDs was reinforced by professional literature being aimed towards women. The men felt much of it was not appropriate for men. They wanted to know whether there were male-specific issues they needed to be aware of or if the existing literature contained everything they needed because the issues were the same regardless of gender:
All the books are directed at women which is even more ‘this shouldn’t be affecting me. This is not something I should have a problem with’. (Henry) It’s [treatment literature] all geared towards women really, yeah. I wouldn’t mind finding out a little more geared towards men really. I don’t know what the differences are, this is the thing. (Greg)
Fear of negative reaction from others if disclose ED
Participants had hidden (and were still hiding) the ED from people for fear of what people would think about them and how they would react. Many found it difficult talking about problems generally but telling people about the ED was particularly difficult because of the fear of how they would respond: ‘If she were to find out she’d be like “What you playing at? Sort yourself out. Get on with it”’ (Henry).
Participants worried that if they told people that they had an ED that others would judge them, not understand, laugh or shun them. Some also worried that loved ones would blame themselves. Some had told people about the ED and were met with disbelief and rejection:
She was kind of offended that the whole time I was with her I felt that way and didn’t tell her but for me, that comes back to it would be seen as a sign of weakness, I don’t want to be seen as a weak person. (Ed)
There were particular worries around employers knowing about the ED for fear of how participants would be judged and treated:
If I’d been in the private sector, I think I would have probably damned my future and it’s because it’s a symptom of not being able to cope, so there’s a suspicion that on one day (…) you going to do something unusual. (Dave)
Difficulty seeing ED as a problem when also a solution
Participants identified that the ED was originally a solution to another problem, such as: managing stress, feeling more in control, providing comfort, suppressing sexuality, regulating distance with others:
There was nothing else to really enjoy, and nothing else I could really control as well … it was a sense of control. I felt that my eating was like an outlet, it just made me happy. (Greg) Part of the thing that I really value about being underweight is that is suppresses my sexuality. (Frank)
Although initially a solution, the ED then became a problem in itself but was difficult to give up due to the benefits it was providing. Some were aware that the ED was a symptom of another underlying problem. The ED was described as being like an addiction: providing a quick-fix solution but making things worse in the long term. The ED and alcohol/drugs were described as serving similar functions but alcohol/drugs also had a relationship with the ED via their influence on weight: ‘I didn’t want to eat the next day so I didn’t ever feel bad about taking drugs it was more … I always felt thin after I’d taken drugs I guess’ (Ed).
Links between ED and discomfort with identity
Participants were uncertain about their identities and found it difficult to know and accept who they were. There was a sense that participants’ identities were influenced by how they were seen by others: both in relation to their overall identity and in specific aspects of identity, such as gender identity. They were sensitive to others’ judgements and compared themselves to others. The ED both made them feel more accepted but also increased their sense that who they really were was unacceptable:
Suddenly because I looked different, wasn’t chubby or fat any more, people reacted to me in a different way, people wanted to get to know me better, wanted to get to know me full stop. The bullying didn’t stop I guess, the names (…) Once I was the fat kid I was always the fat kid I guess. (Ed)
Participants had various struggles with identity conflicts around their gender identities, sexual identities, who they were and their acceptability. Many felt there was something unacceptable about them which had to be compensated for, for example being male when males have undesirable qualities, being someone that deserves punishment or being someone whose interactions with others have resulted in low self-esteem:
You should be blaming the person that’s done it to you but you don’t. You go ‘I shouldn’t have done that, it’s actually my fault’ and so it’s a way of punishing yourself. So you don’t eat. (Colin) It did remind me that I’m not … that I am male. I mean it’s not … I just don’t consider myself in that way. (Bill)
The ED with its prioritization of weight and shape provided a vehicle for feeling more acceptable as a person and other identity conflicts could be masked by feeling acceptable physically. There was a sense of ‘if I’m OK in how my body looks to others, then I’ll feel more OK within myself’. It was important to be physically acceptable as this was the part of themselves that was on display:
It’s like girls, there’s a lot of competitiveness. Um … try to look the best, trying to have the best bodies. That’s why I think women and gay men are quite similar in eating disorders, and in image and things like that. (Anthony) Because I used to be really big, you know, people used to stare at me. So I don’t really want to go back to that. So this whole thing has been, the whole maintaining it and trying to look a certain way. (Greg)
The ED both helped them to feel more acceptable (e.g. lower weight) but also contributed to them feeling unacceptable (e.g. bingeing and vomiting): ‘You could be the most sophisticated, worldly wise, articulate, intelligent, grounded person and they could have an eating disorder, a psychiatrically generated eating disorder. Um … and that obviously disqualified the rest of the qualities that you have’ (Bill).
Experiences of treatment: how important is gender?
Participants described what happened after admitting the ED and that it was a problem, detailing their experiences of treatment and contact with professionals. There was a lack of consensus on whether gender was relevant in treatment, even within the same participant. An ED was thought of as rendering gender irrelevant yet there were examples of different issues for men and women with EDs, and difficulties with mixed sex treatment environments. Within this superordinate theme were the following two themes.
Importance of feeling understood and cared for by professionals
Treatment was often experienced as not being enough in terms of length and also what was on offer. Participants wanted to feel listened to and understood by professionals and found it difficult when this did not happen. However, when they did feel listened to they found it very helpful:
Had I found it more difficult to put on weight I’d have been there for longer and would have had more therapy which I didn’t really get at all. I was effectively there and got fed up, that was it. (Bill) This is helping me because it helps me because I know that people are listening, and they can say ‘try this, try that’. At least they’re listening and you go back on a regular basis. It takes the pressure off. (Colin)
However, they often felt that professionals did not understand what was being asked for and they were given something that was not wanted or not given anything. What was offered was sometimes thought of as unhelpful (e.g. painful/traumatic), or reinforcing previous life experiences. If they had felt uncared for in their lives, it seemed that they sometimes felt similarly uncared for by professionals: ‘I didn’t come out feeling full of joy and happiness “oh I’m being sorted out” sort of thing … more like “10 minutes of his life [the professional] he won’t get back”’ (Henry).
Issue of gender in treatment
There were conflicting views about whether gender was relevant in treatment. There was a sense that having an ED makes men and women more similar than different, and that they face many of the same challenges in treatment: ‘I think it’s pretty much gender-excluding as a disorder. The reasons why you get there are probably slightly different but in the end all roads lead to Rome’ (Bill).
There was also an idea that each individual faces his or her unique challenges which makes them different from everyone else, so it is irrelevant whether they are surrounded by men or women with EDs as they are not the same as any of them: ‘Everyone is different, and ultimately every case is different, and although people suffering from bulimia have got the same thing, it’s probably for a number of different reasons’ (Greg).
Having many people with EDs together was thought to be more detrimental than being the only male inpatient but the difficulty of being the only male on an inpatient ward was also raised:
The gender part is not significant but no … too many people with like mind and that mind is deranged. (Bill) [As the only male] you become aware of people holding back or you being purposely excluded, or people saying ‘maybe it’s best if you’re not in this group because …’ (Bill)
There was also a suggestion that there are different issues for men and women with EDs to address in treatment:
The groups I’d be sitting in on … on the ward with all the women … body image things, they really didn’t bear any relation to … the issues that I had. And also cultural issues as well, because a lot of the time there was this unspoken thing, ‘because we’re women we’re expected to be slim’. I know that wasn’t the issue. That’s never really the issue for eating disorders … it can be a driver I suppose, but that wasn’t for me. (Bill)
Summary of findings and discussion
This study aimed to explore the experiences of men currently in contact with eating disorder services. A qualitative methodology was used to enable participants to discuss the issues most important to them. A strength of this article is the use of rigorous methodology which was achieved by adhering to guidelines for ensuring quality in qualitative research (Brocki and Wearden, 2006; Elliott et al., 1999; Yardley, 2000): this included sensitivity to context through the provision of demographic information about the sample and verbatim quotations to illustrate themes; reflexivity through keeping a research diary; and transparency via an audit trail and independent audit by DS.
The findings build on the findings of previous qualitative studies (Copperman, 2000; Drummond, 1999, 2002) and anecdotal reports (Raevuori et al., 2008), which discussed the invisibility of men with EDs and EDs being seen as a ‘women’s illness’. Indeed, research has found that male cases were less likely than females to receive an ED diagnosis despite identical symptoms (Currin et al., 2007), which suggests professionals find it more difficult to detect EDs in men.
The first key finding was a difficulty admitting the ED, which has also been well documented in the female ED literature (Vandereycken, 2006). The associated findings of links with ED and discomfort with identity and difficulty seeing ED as a problem when also a solution also echo findings from the female literature of impairments in identity development and functions provided by EDs (Serpell et al., 1999; Stein and Corte, 2007; Vitousek et al., 1998). However, it seems that in addition to being a common feature of EDs, there is a unique struggle for men in admitting the ED because of the stereotype that EDs only affect women. Many participants said they were participating in the research because they wanted more to be known about the issue of male EDs as they felt that society perceives EDs as a feminine issue. Previous research (Moller-Leimkuhler, 2002) has shown that men are less likely than women to seek help for emotional problems more generally, and this may also have contributed to participants’ difficulties admitting the ED. If men struggle with the expectations that they and others have of them as men, as well fearing that they are not behaving within the confines of masculine socialization when presenting for therapy (Smart, 2006), this may also have a bearing on how easily they are able to admit to themselves that they have an ED and need help.
Participants also reported a fear of a negative reaction from others if they disclosed the ED. Much consideration has been given to the societal context of female EDs (e.g. feminist perspectives; Malson, 1998) but little attention has been given to the impact of society on men with EDs: for example whether it is acceptable to disclose an ED as a man and how this might conflict with male gender role socialization and masculine ideologies around emotional expression being an indication of weakness. Women may also worry about telling others about the ED, although these findings suggest that there is something in particular about being a man which makes it difficult to disclose the ED. There was a sense that others would think that they were weak for having an ED or they would be ridiculed, which could be related to their perceptions of male stereotypes. However, there was also a suggestion that others would be horrified if they knew, which may be related to shame and disgust around vomiting, for example, and may be similar in both sexes.
The second key finding was around participants’ experiences of treatment, and their differing views of whether gender was an issue. This may have been affected by only two participants having had contact with other ED sufferers (through inpatient and group treatment) and by participants’ constructions of men and masculinity and where they positioned themselves in relation to this.
Also within participants’ discussions of their treatment experiences was the issue of the Importance of feeling understood and cared for by professionals, which has also emerged in the female ED literature (Reid et al., 2008). A large number of women with EDs relate to others with insecure attachment styles, which will also impact on their relationships with services (O’Shaughnessy and Dallos, 2009). This may result in a predisposition to feeling uncared for and may feature in the experiences of both sexes in their relationships with services. This may be further exacerbated for men with EDs through a heightened sensitivity to being different to other (female) service-users with EDs.
All participants were white British or Irish with severe EDs, so it is not clear whether the results would transfer to men with less severe ED symptoms or to non-white men with EDs. The sample was almost entirely outpatients, with only one participant having experienced inpatient treatment in the past, and this may limit the transferability of the findings to male inpatients or day-patients. A number of men declined to participate in the study and it is not known if these men had had vastly different experiences which influenced their decision not to participate. Also, although participants had been deemed to have an ED on admission to the ED service, diagnostic interviews were not used in the research to assess ED status. There was also no assessment of comorbidity: only the participants’ accounts of their difficulties. As with much qualitative research, a further limitation was the reliance on participants’ abilities and willingness to access and report their experiences. It is possible that being interviewed by a female researcher had some effect on participants’ disclosure.
The findings suggest a number of areas in which care for males could be improved, including further training in primary and secondary care to increase identification and raising awareness of males with eating disorders to reduce stigmatization and isolation within both services and society. In particular, males may benefit from being directed towards gender specific information (Men get eating disorders too!, no date; Morgan, 2008) or the option of support groups particularly for males. Consultation with male service-users could facilitate the design of treatment programmes that are inclusive but also relevant for men with EDs. Services should take care not to reinforce the idea that men with EDs are invisible.
Summary
This is the first study to apply a qualitative methodological framework to the experiences of men in contact with specialist services for ED treatment. Emergent themes centred around the difficulty of admitting the ED. Some themes illustrated unique male issues, such as the difficulty of EDs being thought of as a female problem; other themes (e.g. ED as both a solution and a problem) echoed the female ED literature. The results reinforced the importance of individual formulation when considering a male service-user’s maleness and its impact on his ED presentation and treatment preferences. Participants were not uniform in their perspectives and it must not be assumed that there is a unitary presentation of EDs in men. The findings also demonstrate the need to raise awareness of EDs in men: among professionals to facilitate detection, within society to decrease men’s fears of a negative response and among the men themselves to assist in the process of admitting that there is a problem. Although EDs affect many fewer men than women, it is important that this minority population is not overlooked.
Footnotes
Competing Interests
None declared.