PolicyLab

A Google image search for “eating disorders” will return countless photos of young girls and women staring miserably at a plate or at the number on a scale. Yet, these results are not reflective of the true population of eating disorder sufferers.

Despite pervasive myths, boys and men represent between 20 and 25% of those with a diagnosable eating disorder.

Boys with an eating disorder are often misdiagnosed, are less likely to seek treatment than their female counterparts and represent as few as 1-5% of participants in research trials. These statistics are even more pronounced when specifically considering boys and men from historically marginalized groups, such as Black and Hispanic youth.

This lack of accurate representation of who is impacted by eating disorders impedes the screening and treatment for these serious conditions in diverse populations, perpetuates stigma around eating disorders and increases barriers to accessing treatment.   

So it’s time researchers, providers and policymakers do something to change it.

Eating disorders can look different in boys and men

The clinical presentation of eating disorders in boys and young men may appear different from girls and women due to biological sex and/or gender identity. For example, higher levels of testosterone may be protective against disordered eating symptoms. This could mean that eating disorders may onset earlier in boys but not be detected as early compared to girls, who are at highest risk from mid-puberty onwards.

From a gender standpoint, conformity to masculine norms (such as being discouraged to express emotion) has been linked to increased self-stigma related to eating disorder symptoms and makes males less likely to seek help.

In addition to factors related to risk and onset of eating disorder symptoms, studies suggest that boys may also present with differences when seeing their doctor. For example, boys and young men are more likely to report maladaptive exercise behavior (such as secretive exercise or excessive guilt when missing an exercise session) as part of their eating disorder, rather than other purging behaviors. They also may be less likely to express body image concerns or body dissatisfaction as part of their eating disorder, although research from our program at Children’s Hospital of Philadelphia did not find differences in parent or adolescent reported reasons for onset across boys and girls presenting with anorexia nervosa.

Supplementing eating disorder screening can help providers catch symptoms

Most research in eating disorders has focused on adolescent girls and young adult women, including the development of most screening and assessment tools.

Experts have expressed concerns with the screening tools that are used most prevalently, especially with their ability to accurately identify eating disorders in boys and individuals with marginalized identities. A newer measure has shown promise in identifying eating disorders in boys but it’s lengthy and difficult to implement broadly.

To compensate, primary care physicians and other health care providers may need to supplement existing screening tools alongside height and BMI trajectories to identify youth falling off of their expected growth curves. They may also need to discuss changes in eating behaviors or preferences with both adolescents and parents and ask openly about exercise behaviors or attempts by adolescents to change their weight or shape. Importantly, boys with a history of higher weight may be at particular risk for developing an eating disorder, which can lead to a more prolonged eating disorder course before recognition and greater risk of long-term illness and more severe medical complications.

Addressing unexpected weight/BMI fluctuations early with youth of any gender identity, even if these behaviors are under the guise of increasing health, may help to catch eating disorders in their early stages and facilitate the provision of education related to the need for regular, adequate eating during adolescence.

We need more energy behind policies that specifically address boys’ health needs

Over the past several years, increasing attention has been devoted to policy approaches that aim to help all youth at risk for or suffering from eating disorders.

Experts have called for increased regulation on appearance and performance-enhancing drugs and substances (also known as muscle-building supplements), which are disproportionately used by boys and men. Legislation to limit the sale of these products to minors has been successful in New York, and is currently being considered in five other U.S. states.

To increase awareness, decision-makers in at the state, district, and even school levels can incorporate eating disorder awareness in health education. Experts throughout the U.S. have developed model legislation to be moved forward at the state level, and PolicyLab has published an issue brief detailing steps to broaden inclusivity in school health programs. Schools can also reflect this priority in their school wellness plans, which are crucial district-level policies required by the Centers for Disease Control and Prevention that outline how a school will support all students’ nutrition and physical activity needs.  

Though often overlooked in research and in public conversation, boys and men are significantly impacted by eating disorders and disordered eating. To improve equity in care, we must consider the ways in which boys and men may present differently and similarly to young girls. By shifting the public conversation to include boys and men with eating disorders, educating health care professionals and policymakers, and increasing the accuracy of screening tools, we can better serve this population and improve outcomes for all who suffer from an eating disorder.  

Marita Cooper, PhD, is a former affiliate trainee at PolicyLab.