Boys are beyond the range of anybody’s sure understanding, at least when they are between the ages of 18 months and 90 years – James Thurber

As a clinical psychologist working in the field of eating disorders, when people find out what I do, I am often asked, “Do you ever see teenage boys struggling with eating disorders?” I try to answer this question as directly and honestly as possible. “Yes, but far less often that I would expect”. People seem surprised by this answer, both that boys struggle with eating disorders and that I would expect to see more of them presenting for treatment. Let’s look at the facts.

– Adolescent males comprise approximately 5-15% of cases of anorexia nervosa and bulimia nervosa (Becker, Grinspoon, Klibanski, & Herzog, 1999).

– Approximately 40% of cases of binge eating disorder (BED) occur among adolescent males (Becker et al., 1999).

– Kjelsås and colleagues (2004) found that 6.5% of males met diagnostic criteria for an eating disorder, with most males meeting diagnostic criteria for Eating Disorder Not Otherwise Specified (EDNOS).

– A recent study by Dominé and colleagues (2009) found that approximately half of adolescent males in a community sample reported experiencing some concern about their eating, with approximately 20% describing having engaged in at least one type of disordered eating behavior (e.g., self-induced vomiting).

– The National Eating Disorders Association estimates approximately 10 million males in the United States struggle with an eating disorder.

So I am left wondering, why is it that we do not we see many males in treatment, and what are the barriers? Some have argued that current diagnostic classification systems (e.g., DSM-IV) could do better at capturing adolescent males’ experiences of eating disorders and that clinicians have a higher threshold for diagnosing eating disorders in males (Muise et al., 2003). Others, like Dr. James Lock, have commented that valid and reliable measures of boys’ symptomology are lacking. In general, what we know is that they are out there, and they are not getting help. A recent piece on ABC News entitled, Men with Eating Disorders Have Tougher Time Getting Help, highlights the struggle adult males and their families go through to access services and points to answers from the world’s leading professionals on why this may be the case (please see link to story below).

Help-Seeking Behavior as a Barrier for Reaching Males

We face a number of barriers when reaching males with eating disorders. At the individual level, one major challenge is help seeking behavior. There are two sources from which adolescents generally seek help: informal sources, such as family and friends, and more formal sources (e.g., guidance counselors, physicians, psychologists, etc.). Help seeking can be divided into three stages: (1) recognizing there is an issue; (2) deciding to seek assistance actively for the issue; and (3) selecting a source of help (Anderson, 1995). Unfortunately, only a small proportion of youth will seek out professional sources of help when faced with a serious problem. In fact, the National Survey of Mental Health and Wellbeing revealed that only 29% of youth with a mental health concern had actually sought professional help over a one year period (Sawyer et al., 2000). It is also known that boys, in general, are less likely to seek help than girls, and that even when they do seek assistance, they are more likely to turn first to informal sources like friends and family before they consult a professional (Boldero & Fallon, 1995; Schonert-Reichl & Muller, 1996). This becomes even more complicated within the field of eating disorders when we take into consideration that adolescents with eating disorders present a unique challenge; the illness is ego-syntonic (i.e., consistent with one’s self-image; not something a person wants to get rid of)  in that youth typically do not want to engage in recommended treatment in the first place. Not only does this place them at greater risk for not seeking help and being formally identified, but it also increases the chances of treatment dropout when they do actually access formal sources of support.

Reaching and Engaging Boys in Treatment

There are a number of ways we can facilitate adolescent males’ engagement in help seeking. First, knowledge is power and a catalyst for change. Providing adolescent males with psychoeducation on the nature of eating disorders and the role of biology and genetics has been suggested to help with reducing stigma surrounding seeking formal support. Although the data on how effective this is as a strategy in males is lacking. Helping them to understand that biology is at play, but that biology is not necessarily destiny may be essential. Second, seeking out boy’s informal support networks (e.g., friends, teachers, athletic trainers, and coaches) and educating them about eating disorders and how they manifest specifically in boys is important. We cannot expect the informal sources of support to be able to recognize the signs and symptoms unless they are aware of those signs themselves. Further, we need to begin to challenge some of the common misperceptions that get in the way of us seeking support for the males in our lives (our fathers, sons, friends etc.). Challenging thoughts like “he is just stretching out”, “don’t worry, he will fill out”, or “he is just going through an exercise phase or a healthy phase” will go a long way in facilitating formal help-seeking.

Lastly, in order to have someone be willing to seek help, they must perceive that it will in fact be helpful. Perceived helpfulness is an important variable that can positively impact the decision to seek professional care. Many of the traditional approaches to treatment are perceived as undesirable to boys (e.g., sitting in talk therapy), even though they may result in symptom reduction. Boys actually report finding action-oriented services that utilize multimedia activities, sports and recreation, and a hands on approach more helpful than traditional counseling (Smith 2004). Combining therapy methods that have been shown to be effective while integrating action oriented treatments (e.g., Cognitive Behavioral Therapy offered online, Cognitive Remediation Therapy) may help to get boys engaged and on the road to recovery.  We need more research on how best to adapt treatments for boys that incorporate these principles known to make a difference in how boys engage in and respond to treatment.

Selected References

ABC News (Feb., 2013). Men with eating disorders have a tougher time  getting help.   http://abcnews.go.com/Health/anorexic-men-harder-time-diagnosis-treatment/story? id=18591296#.UWxUb7Xqn44

Becker A. E., Grinspoon S. K., Klibanski A., & Herzog D. (1999). Eating     disorders. New England Journal of Medicine, 24, 1092–1098.

Boldero, J., & Fallon, B. (1996).  Adolescent help-seeking behavior: What do they get help for and from whom? Journal of Adolescence, 18, 193-209.

Dominé F., Berchtold A., Akré C., et al. (2009). Disordered eating behaviors: What about boys? Journal of Adolescent Health, 44, 111-17.

Muise, A.M., Stein, D., & Arbess, G. (2003). Eating disorders in adolescent boys: A review of the adolescent and young adult literature. Journal of Adolescent Health, 33, 427-35.

Schonert-Reichl, K., & Muller, J. (1995). Correlates of help-seeking behavior in adolescence. Journal of Youth and Adolescence, 25, 705-731.

Smith, J. M. (2004). Adolescent males’ views on the use of mental health counseling services. Adolescence, 39, 77-82.

By: Brad Mac Neil, PhD, Licensed Clinical Psychologist

Photo by: MoodBoard Photography