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Thinner: The Male Battle With Anorexia

Thinner: The Male Battle With Anorexia

Thomas Holbrook often wonders, as he stands at the lectern and tells his story, what his colleagues in the audience are thinking. Are they disgusted? Bored? Disbelieving? He scans the rows of faces, but finds them without expression.

“They’re not moving, they’re not talking,” Dr. Holbrook said recently. “And I’m thinking, ‘What the hell am I doing? They just think I’m a fool.'”

Only after he has finished, when he has told them about the years spent “starving myself and exercising 20 hours a day,” about the loss of his marriage, the suicide of his father, the obsession with food and fat that controlled his every waking moment, only then do they tell him that they think he is brave, congratulating him on his struggle to regain his health and on his openness in sharing his experience with others.

Dr. Holbrook, a psychiatrist and former director of the eating-disorders program at Rogers Memorial Hospital in Oconomowoc, Wis., is not most people’s idea of a recovering anorexic. But then, most people think of anorexia nervosa and its relative, bulimia nervosa, as women’s diseases. Yet in a culture in thrall to the god of physical attractiveness, where image, as the slogan goes, is everything, women are not alone in their vulnerability. Men, too, suffer from eating disorders, though at lower rates than women.

And new research suggests that the number of men who have significant symptoms of eating disorders may be greater than was once believed: in a study of 10,000 residents of Ontario, for example, University of Toronto researchers found that 1 of every 6 people who qualified for a full or partial diagnosis of anorexia was male — substantially more than the 1 in 10 usually reported in studies of patients in eating-disorder programs.

Some experts also suspect, though data are still scarce, that eating disorders among men are on the rise, increasing along with the pressures men feel to conform to the lean and chiseled stereotypes purveyed by Hollywood and Madison Avenue. “We are seeing a tremendous increase in men’s distress about their body shape,” said Dr. Arnold Andersen, a professor of psychiatry at the University of Iowa College of Medicine, who specializes in eating disorders. “I think that men are simply following a decade or two behind women in terms of being exposed to body images that are increasingly difficult to achieve.”

Women with eating disorders may be driven by their desire to be thin, but men often express their preoccupation in different terms. Instead of a low body weight, they seek well-defined muscles, sleek abs and sculptured pecs. Achieving this goal, however, usually means excising every stray ounce of fat. If the anorexic or bulimic woman’s nightmare is being told that she has “a little meat on her thighs,” many men live in fear of being told that they “still have a little fat on those delts.”

For example, Dr. Holbrook, who is 57, said he did not consciously worry about being overweight until 1976, when an injury forced him to stop running his customary 15 miles a day. “When I couldn’t run any more, I panicked,” he wrote in “Making Weight: Men’s Conflicts with Food, Weight, Shape and Appearance,” (Gürze, 2000), which he wrote with Dr. Andersen and Leigh Cohn. “I started weighing myself every day, and even though I was not gaining weight, I started feeling fatter. For the next 12 years, I did everything I could to rid my body of ‘the fat.’ ”

Like other men who have had eating disorders, Dr. Holbrook said he remembered feeling undersize and physically inadequate as a child. He began exercising compulsively, he said, in part to feel more powerful, though it also helped him cope with having an alcoholic father and an emotionally unpredictable mother. “I grew up in the era of Charles Atlas and superheroes, and soldiers, and all the mystique of the strong, courageous man,” he said. “It may appear in a somewhat different form now, but I think that it is still a prized stereotype, and I think that has a tremendous impact on vulnerable people.” That no one, not his colleagues at the eating-disorder program where he worked or his family or his closest friends, commented on his obsessive behavior — he walked six hours a day and often survived on a few rice cakes for lunch — is typical of men’s experiences with eating disorders, Dr. Holbrook said.

In fact, men appear less likely than women to recognize their symptoms as those of anorexia or bulimia, and seem more reluctant to seek professional help. That so few men come to hospitals and clinics for treatment “probably has something to do with the fact that these are labeled women’s illnesses,” said Dr. Blake Woodside, an associate professor of psychiatry at the University of Toronto and a co-investigator on the Ontario study, which has been presented at conferences but has not yet been published. Dr. Woodside noted, for example, that “men get breast cancer, but they don’t show up in breast cancer clinics either.”

Some studies have suggested that homosexuals are overrepresented among men with anorexia and bulimia who do seek treatment, perhaps because they are more willing to identify themselves as having an eating disorder or because gay male culture puts a premium on trimness and physical appearance. “There is nothing about gayness itself that increases eating disorders,” Dr. Andersen said, “but there is a lot in the fact that the community has highly stereotyped norms for what is attractive.” Other researchers have found no relationship between homosexuality and eating disorders, and the association remains debated.

Much more striking than the differences between men and women with eating disorders, many researchers say, are the similarities. Like women, men with anorexia or bulimia struggle with perfectionism and low self-esteem. They seek to gain control over their lives by controlling their bodies. They often suffer from depression, anxiety, alcohol or drug abuse or other psychiatric conditions in addition to their eating-related symptoms. Most have a severely distorted image of their bodies, seeing obesity in the mirror where others see skin and bones.

In a study of patients admitted to the eating-disorders program at the Westchester Division of New York Presbyterian Hospital, Dr. Katherine Halmi, director of the program, and her colleagues found few differences between the sexes. Bulimic men, for example, were just as likely as women to use self-induced vomiting as a means of purging food after binge-eating, although they were slightly less likely to abuse laxatives. They also struggled with many of the same psychological issues. Men who were admitted to the program, however, were more likely than women to have been involved in sports, like wrestling, biking or diving, that required weight control, Dr. Halmi said. And the age when eating problems began was slightly later for men than for women. Women had often exhibited the first symptoms of the illness between the ages of 14 and 15, the researchers found, while in men, who reached puberty later than women, symptoms were more likely to have begun between ages 15 and 16.

Dr. Andersen, of the University of Iowa, says purging, either through exercise or self-induced vomiting, may be adopted by some men because dieting is not as socially acceptable for men in American culture as it is for women. “A guy does not order lettuce salad with no-fat vinaigrette, poached sole with no butter and Jell-O for dessert,” Dr. Andersen said. “The guy would look weird. But he’s got to get rid of the food if he can’t say no.”

The physical consequences of a long-term battle with anorexia or bulimia are equally devastating for men and women. Like anorexic women, anorexic men can exhibit all the physiological signs of starvation, including cardiac irregularities, severe dehydration, thinning hair, bruising skin, osteoporosis and sensitivity to cold. While in women with anorexia, estrogen levels drop and they are likely to stop menstruating, in men, testosterone levels plunge, and sexual desire vanishes. If patients do not receive treatment, or if treatment is unsuccessful, death is too often the result.

Bulimic men, like bulimic women, can suffer electrolyte imbalances, intestinal problems, enlarged salivary glands and erosion of the enamel on their teeth. Treatment for eating disorders in both sexes is similar, involving a combination of antidepressants or other medications and psychotherapy. Studies have shown that cognitive behavioral therapy, which focuses on distorted beliefs and thinking patterns, is effective in many cases.

Severely ill patients, particularly patients with severe anorexia, may require hospitalization. Yet to receive treatment, men must recognize that they are suffering from an eating disorder. For Dr. Holbrook, the realization came in 1988, when an anorexic woman he was treating asked him one Thursday whether he was sure he would be back in the office on Monday. He was taken aback, and tried to reassure her. “I don’t abandon my patients,” he told her. She was not convinced. “My head says ‘yes,’ ” she replied, “but my heart says ‘no.’ ”

Two days later, Dr. Holbrook stood in his kitchen, staring out the window, and heard her words again. He ticked off the symptoms of anorexia: he had them all. Abruptly, shame and sadness overcame him. “It is still very strange to me that it happened that way,” he said recently. “But it wasn’t really a shock. It was sort of like I had known about it all the time.” That morning, there was no longer any question or room for pretending. He turned away from the window, and slowly began the long process of healing.

Reprinted with permission from The New York Times
By Erica Goode


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