Dr. Melinda Parisi joins us to discuss clinical issues in the treatment in men and boys with anorexia. Unfortunately, there are still some people who think eating disorders only affect women – Dr. Paresi explains how eating disorders can affect all populations, and takes a deep dive into the issues clinicians can face in treating men and boys with anorexia nervosa.
Dr. Parisi serves as the program director for the Center for eating disorders care, as well as administrative director of hospital psychiatry at the University Medical Center of Princeton. She has held faculty appointments at Chestnut Hill College, Immaculata University and the College of New Jersey and has written, and presented extensively on assessment and treatment of eating disorders. Dr. Parisi earned her master of science and education from the University of Pennsylvania and her doctoral degree from Fordham University.
Full transcript –
Kathy: Hello and welcome to ED matters. This is Kathy Cortese, your host. Today I’m here with Dr. Melinda Parisi. Welcome Mindy.
Dr. Parisi: Thank you for having me.
Kathy: Dr. Parisi serves as the program director for the Center for eating disorders care, as well as administrative director of hospital psychiatry at the University Medical Center of Princeton. She has held faculty appointments at Chestnut Hill College, Immaculata University and the College of New Jersey and has written, and presented extensively on assessment and treatment of eating disorders. Dr. Paresi earned her master of science and education from the University of Pennsylvania and her doctoral degree from Fordham University. Our topic today, specifically, is clinical issues in the treatment of men and boys with anorexia. To start us off Mindy, what can you tell us about the frequency of occurrence in the male population for specifically anorexia nervosa?
Dr. Parisi: Sure. A surprisingly difficult question to answer believe it or not. As you know eating disorders and anorexia nervosa in particular have been historically viewed as female illnesses, both by treatment professionals and by society at large. Clinical and case studies as well as a D.S.M. five report that males for count for about ten percent of all patients who have anorexia nervosa. But population based studies more recently have suggested that up to twenty five percent of people with anorexia nervosa are males. It’s somewhere in between there. We’re not exactly sure. If you add to that the fact that subclinical eating disorders are not reported in those numbers. Things like subclinical eating disordered behaviors things like binging, purging, laxative abuse, fasting for weight loss, those behaviors are can be nearly as common as among males as females, so that complicates the picture even more.
Kathy: Just for our audience so people understand the definition of subclinical, a brief explanation of that.
Dr. Parisi: Yeah. Behaviors that reflect disordered eating, but don’t necessarily rise to the level of a diagnosable eating disorder. Fasting behaviors where there isn’t the amount of weight loss that you might see in diagnosed anorexia nervosa. Binging and purging behaviors that don’t occur with the frequency that would be needed to make a diagnosis of an eating disorder, things like that. Behaviors that are problematic in their own right but not necessarily diagnosable as an eating disorder per se.
Kathy: Thank you. Can you talk please about the stigma regarding boys, men and anorexia. Because there’s a stigma with anybody with anorexia, but now we’re speaking about males.
Dr. Parisi: Yes. You’re absolutely right. Stigma is a big problem and it exists for all folks with eating disorders, but when it comes to males with eating disorders that can become even more of a problem. As we talked about there is a gender bias and so there’s a gender bias in understanding the disorder and society tends to view it as a female problem. Many people simply lack awareness that it’s possible for a male to have an eating disorder. Because it’s publicized more by the media as a problem only girls and women face, males may be more reluctant to come forward and admit that they have a problem. It may be more difficult for them to admit that they have a problem that’s traditionally been associated with females. They may not report it. They may not seek treatment. If you think about what is, how do you insult a boy on the playground at school? You fill in the blank, like a girl. If you kind of take that and have a boy or male struggling with a disorder that is historically seen as female, it may impact their sense of self, much more so, than if it were female with that disorder. It may clearly impact their help seeking behavior and that’s a real problem because delays in diagnosis and treatment are associated with, not as good outcomes. It’s important that we’re able to identify this sooner and get folks into treatment as quickly as possible.
Kathy: As things get more complex and perhaps the eating disorder is taking hold this gender bias, is going to sort of flow throughout perhaps the family, the family friends, the school and the people who might be professionally assessing. The male, and when I say the male, I want us to also understand that we’re talking about middle aged men. We’re not just talking about teenage boys or early twenties. We’re talking throughout the lifespan. Your thoughts on how people can get an accurate assessment, what would you want people to know?
Dr. Parisi: I think the important thing is to really recognize and bear in mind that eating disorders, anorexia can and does affect boys and men and it’s not simple. Even clinicians, it’s not just society at large but even clinicians bear that bias when it comes to diagnosing eating disorders. I recently worked with Jessica Whitney at Fordham University on her doctoral dissertation. I was a reader on her dissertation and she did a qualitative study of mothers and she interviewed mothers who had boys with eating disorders and talked about their experiences with it. She found that in more than half of the mothers that she interviewed, a frontline provider, doctor, pediatrician and E.R. doctor did not consider an eating disorder or did not consider anorexia nervosa specifically as a potential cause of the physiological problems that their sons were presenting with, and of those if some of them actively dismissed it when the mom raised, “Hey, might my son have an eating disorder”. They said, “No, that cannot, it’s not what it is”. If we as clinicians don’t recognize it and I think in the eating disorders community we’ve done a better job of recognizing eating disorders and boys and men. As health professionals we need to be more aware of the potential for an eating disorders diagnosis in order to get, again, boys and men that help that they need. Going back to the issue of stigma though, I think the other thing that happens is boys and men with eating disorders may feel a profound sense of shame for having a disorder that has traditionally been associated with women. There’s, again, there’s not a lot of literature on eating disorders in boys and men, but if you look at the literature on men with breast cancer which is a gender atypical illness, they report feeling very ashamed, marginalized from treatment.
Kathy: Isolated, I’m sure.
Dr. Parisi: Very isolated because they feel like that this is borne out in that data that they tend not to talk about their illness. The kind of social support that goes a long way towards healing for people, men with a gender atypical illness tend not to talk about it to anybody but their closest family members and closest friends, so they tend to be much more socially isolated. That becomes an important consideration.
Kathy: Thank you for that. Difference is, in terms of the presentation in boys and men, what would the clinician be noticing that might be different than what they would see in females?
Dr. Parisi: A few things, I mean, in a lot of ways a presentation is very similar in terms of the symptoms that they present with the risk factors are very similar, as well as the psychological features. The differences can actually be fairly subtle. One is that males are more likely to have been overweight before the onset of anorexia than females, which can actually further complicate getting a diagnosis because it may be perceived as quote unquote normal weight loss up until that point.
Kathy: Yet there may still be malnutrition?
Dr. Parisi: Without a doubt.
Dr. Parisi: Without a doubt. A patient may look physically, visually rather look normal but physically be very ill. That’s an important piece. Females may tend to be more focused on weight and thinness, try for thinness. Whereas, males may be more focused on looking fit, looking muscular, having a certain body type especially a certain body type associated with playing a sport. They may be more focused on exercise as a means of weight loss or again or the means of attaining fitness and exercise becomes obsessive and problematic. Another factor that makes it perhaps more difficult to diagnose because it’s not as overtly associated with weight loss. Male patient may be perceived, again, is getting fit, playing sports. Those are activities that are generally rewarded for people especially for males. It may not be seen initially as something that’s a problem.
Kathy: The slippery slope of, “I’m going to the gym”.
Dr. Parisi: Exactly.
Kathy: This is what I did today and I did this cardio and..
Dr. Parisi: Exactly. Everyone’s like great. Go for it. But it’s really masking a bigger problem.
Kathy: What can you tell us about some of the clinical issues in this population?
Dr. Parisi: There’s some important issues, again, I want to note that there’s not a lot of research. One thing is that we need to do more research on the clinical issues in treating boys and men with anorexia. One thing though, is that when we’re looking at weight restoration because of their higher muscle, mass boys and men may need to be at higher target weights than girls and women, and men may be at higher risk even when their weights are higher. That’s important not to overlook. They may also have much higher energy expenditure needs, so they may be need to be on higher calorie levels in order to gain weight. That can be difficult in the re-feeding process for men.
Kathy: I imagine for families too. We live in this diet obsessed culture and if a family hears my kid is eating five thousand calories a day.
Dr. Parisi. Yeah. Absolutely.
Kathy: Would not be so unusual.
Dr. Parisi: That wouldn’t be unusual. I mean, we’ve certainly seen that here.
Dr. Parisi: Yeah, that’s an important piece. Also the issue of social isolation, again, boys and men with anorexia may be more socially isolated than their peers. Family support is important for all of our patients with eating disorders, but maybe particularly a point important for boys and men because they may, again, that social isolation put pieces, so real for them. Other treatment considerations are things like group therapy at the kinds of things we’re asking boys and men to do when they come into treatment. Boys and men are not generally socialized to talk about their feelings, to be in touch with their feelings. Well, with most feelings, anger is okay, but other feelings particularly more vulnerable feelings, men are not encouraged to share those feelings. When we have someone come into treatment and expect them to all of a sudden kind of lay everything out on the table and be in touch with their emotions, that may be really a foreign idea for boys and men. Patience is important and to not kind of dismiss them as being superficial, but to recognize that this is an important socialization difference. I remember covering for a therapist and leading an adolescent group one day and we had an adolescent boy come into treatment and he was, it was his first day in group therapy and patients started going around the room, and starting to talk, and they got to him, and he was like, “This is stupid”. That was his first kind of contribution, like, “You want me to talk about my feelings?”, “What are you talking about?” It was just, could not wrap his head around the whole idea of sharing his feelings in group. The girls in the group had a strong reaction to that. It kind of had to work with. Well, “What’s it like for you to have to do this?” “This is not a usual experience for you.” Talking with him about that really respecting that in him and not saying, “Oh, there’s something wrong with that”. I think that’s important.
Kathy: That speaks to a very large in issue when it comes to recovery and that is getting in touch with the self and understanding one’s feelings, and yes lots of different recoveries but definitely eating disorder recoveries to know what’s going on inside for you. I can imagine how hard it must be for a male in that position to just sort of be trust and encouraged. Yet ,they do.
Dr. Parisi: They do. In fact, this young man really, once he felt more comfortable, really quite enjoyed it. Working with boys and men on, there is more than one way to express masculinity and be a man in the world and that it’s okay, and it’s okay to be vulnerable and it’s okay to have vulnerable feelings. That can go a long way towards kind of challenging some of their assumptions and the way they’ve been socialized.
Kathy: You’ve touched on some other challenges that boys, men in their families might experience as they launch into treatment?
Dr. Parisi: Yeah. A lot of males may approach coming into treatment with a lot of concern. What’s it going to be like? Am I going to be the only male? In fact, that’s often a concern for males and if it’s possible to be in the treatment setting where there are more male patients. I think that’s important that males have the opportunity to talk to their male peers because they are often going through something a little bit different than what their female peers are going through. Again, there’s a lot of similarities but there are things that are different. I’ve heard male patients talk about, “Am I going to come into treatment?” and, “Are the walls going to be covered with pink butterflies?” That’s been their experience in some places, so they approach it with some trepidation. Things like, the decor which sounds like a nothing is important.
Dr. Parisi: Things like, what kinds of leisure activities are available for males? We had an adolescent boy several years ago who got back to sometime after treatment. He was doing really well and he get back and said, “I really want to thank you for everything that we did, but I gotta tell you, you need more stuff for boys and can I help you with that?” It actually proceeded to raise money and have people donate items. He kind of took it upon himself to do that because he felt it was so important. Things like that, what leisure activities are available. If you have a community area where there’s one T.V. and everybody has to agree on what we’re going to watch and all of the women want to watch, the girls and women want to watch one thing, and you have one male patient, nobody wants to watch football. Things like that. Where you can have a core group of male patients, if you can have a group of patients that can relate to each other and talk to each other on that level. I think that’s very helpful.
Kathy: Right. In terms of what you’ve been seeing over your time, you’ve been in the field a really long time. Not to say that you’re old.
Dr. Parisi: Let’s not count the years.
Kathy: What are you seeing when it comes to males? Are they stepping forward more? Are we having more support for their involvement in recovery and family support in recovery?
Dr. Parisi: I would say, we are definitely seeing here more males than we have in the past. I mentioned some studies, look saying maybe twenty to twenty five percent of people with anorexia are male and what we’re seeing here at Princeton really bears that out at any given time. We have tend to have more than a few males in treatment with us, which is great because again, there’s a sense of..
Dr. Parisi: Shared experience. Exactly. Where they can have similarities with the female patients but they also have kind of a group of male patients that they can relate to in their own way. Definitely, we’re seeing more patients here with anorexia.
Kathy: Are you seeing changes in the families, as well as they have their sons or husbands, etc, brothers come in for treatment in terms of, let’s just say their readiness to be involved?
Dr. Parisi: I think in general, families want to be involved and they come in and they’re really scared and they need their own support. They’ve experienced, unfortunately, some degree of exclusion or marginalization at times. It’s important to really look at what are their needs as family members and how do we help to take care of them and so part of that is looking at, well, do they have any unique experiences as a family member of a male patient with anorexia that needs to be addressed in some way and being sensitive to that?
Kathy: I can only imagine how rich and productive that kind of conversation must be for everyone to hear.
Dr. Parisi: Yeah. I think it’s really important to validate people’s experiences. Sometimes people coming into treatment have had some not so good experiences that they need to be heard and they need to share.
Kathy: In closing, do you have some thoughts about, perhaps something we, I didn’t think to ask or anything you’d like the audience to hear?
Dr. Parisi: Yeah. I think it’s really important to note that even with all of these issues that we’ve talked about.
Kathy: The challenges.
Dr. Parisi: The challenges. Recovery is possible. People can and do recover from eating disorders and there is good treatment available. So, again, I want to reinforce the importance of getting the right diagnosis, getting into treatment, overcoming those barriers to treatment because with treatment people can and do recover and have very good outcomes.
Kathy: Thank you so much. My guest today has been Dr. Mindy Parisi. This is E.D. matters. Thank you for your time.