Addressing the Importance of Gender in Psychotherapy of Eating Disorders
by Douglas W. Bunnell, PhD, FAED, CEDS
Within the past decade, there has been a vast increase in research on eating disorders. We now understand that these serious illnesses are caused and maintained by a large constellation of genetic, temperamental, interpersonal, physiological, and developmental factors. Yet, in contrast to earlier conceptual models of these disorders that emphasized the role of gender and femininity, the issue of gender is largely missing from our more current paradigms and our treatment models. Eating disorders are, in fact, gendered illnesses. The thoughts, beliefs, anxieties, and behaviors that define the disorders all reflect aspects of gender socialization. This is true for women with these disorders, still the substantial majority of sufferers, as well as for men and transgender clients.
Therapists can use the exploration of gender as a gateway to a deeper understanding of their clients’ eating disorders. That exploration also presents critical opportunities for enhancing therapeutic motivation and building therapeutic alliance. Gender and gender identity are largely social constructs, built on a biological foundation but continually evolving on the basis of life experiences. Gender identity, increasingly, is seen as nonbinary. Clinicians working with transgender and gender-nonconforming clients should familiarize themselves with current practice guidelines for this population (apa.org/practice/guidelines/transgender.pdf). Gender, however defined, does shape most of our social interactions, including early attachment experiences, and thereby builds, through internalization, the foundation of self-identity. Gender, for all of us, shapes our sense of power, autonomy, rules about emotional expression, and role expectations in relationships. For our clients with eating disorders, their experiences of masculinity, femininity, or other gendered identity will also clearly influence their experience of their bodies, attitudes about weight and shape, and rules and expectations about eating.
At the higher levels of symptom acuity, eating disorders trump gender. The nutritional chaos of emaciation, binge eating, purging, overexercise, and other eating-disordered behaviors can, however, obscure essential gender differences in the key motivations and maintaining factors for the eating disorder. Women with eating disorders are, in general, motivated to lose weight or to avoid weight gain. Weight loss, attaining and maintaining a thin body ideal, and disciplined control over eating tend to be ego-syntonic—that is, female clients are often ambivalent about making changes in treatment that move them away from those goals. Men and boys with eating disorders are often less ambivalent about weight gain but tend to be more focused on a body ideal that is muscular and lean. There are other significant differentiators between men and women with eating disorders, including historical factors such as teasing and relational trauma, premorbid weight histories, and the behavioral constellations and motivations behind exercise and substance abuse risk (see Bunnell, 2010; Strother, Lemberg, Stanford & Turberville, 2012, for further details about these differences).
A client’s adherence to conventional masculine norms or feminine norms may actually shape the nature of that person’s eating-disordered beliefs, motivations, and behaviors. Adherence to feminine norms, for instance, was found to be associated with a greater drive for thinness and weight loss. Adherence to masculine norms was associated with a drive for muscularity and a lean or “cut” body type (Pritchard, 2008). A recent case study on eating disorders in transgender clients suggested that the focus of their disordered beliefs and anxiety for these individuals shifted as they transitioned from one primary gender identity to the other (Murray, Boon & Touyz, 2013).
Many of these gendered differentiators are often camouflaged and difficult to define. In fact, most of the assessment inventories we typically use for diagnosis and treatment planning have been normed on female populations (Strother, Lemberg, Stanford & Turberville, 2012). Because they tend to assess the key thoughts, beliefs, and behaviors associated with women with eating disorders, they underestimate the degree of symptom severity for males. Questions focused on drive for thinness, for instance, may not be relevant for a male with an eating disorder who is actually driven by a desire to develop muscles or to cut body fat. Attempting to define thresholds for binge eating is complicated by different gendered social norms. Overeating for men is more socially acceptable than it may be for women. Overexercise in men may also be seen as socially and culturally desirable, at least more so than for women. This complicates the process of diagnosing men who compensate for binge eating with exercise. There are newer assessments, such as the Eating Disorder Assessment for Men (EDAM), now available to help address this gap (Stanford & Lemberg, 2014).
Most of what is known about the treatment of eating disorders is based on research on women. The conceptual models used to develop treatment interventions tend to address motivations, feelings, beliefs, and relational expectations that are relatively feminized. For instance, in CBT transdiagnostic models for eating disorders, overvaluation of shape and weight are critical maintaining factors (Fairburn, Cooper, et al., 2009). Yet, with an eye on gendered distinctions, clinicians recognize that men define body acceptance in ways that are often quite different from female standards. Schmidt and Treasure (2006) see pro-eating disorder beliefs as one of the key factors that maintain eating psychopathology. The nature of these beliefs is likely to be substantially different for male clients. While treatment often requires a focus on the ways in which clients may feel enhanced by their eating disorder, men, as Cohn (2010) has stressed, are less likely to feel that they are improved in some way by their struggle with food and body.
Gender is then a powerful organizing principle for the self and a major influence on the expression and nature of eating disorder symptomatology. It also shapes the psychotherapeutic relationship. Psychotherapists can use a careful exploration of their clients’ gendered experiences to help build an individualized and nuanced conceptualization of their eating disorders. Appreciating the essential gender distinctions described earlier allows the therapist to engage in a more precise and validating exploration of the motivations, anxieties, beliefs, and perceived benefits of clients’ eating issues. That exploration is further enhanced by the therapist’s careful and ongoing self-assessment about his or her own gender experiences, biases, and blind spots. Male therapists working with male clients may be prone to collude with the masculine norm of avoidance of emotional topics. Female therapists, on the other hand, may implicitly or unconsciously see their male clients as less emotionally sophisticated. Therapists, regardless of their own gender, need to monitor their own emotional reactions to gendered issues that play out in therapy. How do you react differently to male, female, transgender, or gender-nonconforming clients when they express anger, sadness, need, envy, or sexual or erotic feelings? Differences in responses do not reflect failure; they represent an opportunity for the therapist and the client to explore and refine an understanding of how gender and gender expectations are affecting the relationship and, most important, how they are perpetuating the eating disorder. Careful attention to these issues can help build and sustain alliance and motivation (see Bunnell, 2015; Bunnell, 2010; Maine & Bunnell, 2010, for a more detailed exploration of these issues).
Eating disorders are gendered illnesses. Men, women, and transgender clients with eating disorders have unique motivations and eating-related concerns that reflect their gender socialization. Therapists working with clients with eating disorders can use the careful exploration of these gendered experiences to help develop an individualized, rich, and complex understanding of the factors that are perpetuating their clients’ eating disorders. In monitoring their own gender biases and gendered countertransference, therapists can help build a gateway to deeper feelings that will enhance therapeutic alliance and build and sustain motivation.
About the author –
Douglas W. Bunnell, PhD, FAED, CEDS is the Chief Clinical Development Officer for Monte Nido & Affiliates. He is a past board chair of the National Eating Disorders Association, a member of NEDA’s Founders Council, clinical advisor for the NEDA Navigator Program and a recipient of NEDA’s Lifetime Achievement Award. Dr. Bunnell is a co-editor of Treatment of Eating Disorders: Bridging the Research Practice Gap.
American Psychological Association (2015). Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. Retrieved from http://www.apa.org/practice/guidelines/transgender.pdf.
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