Why are Men Treated Differently for an Eating Disorder (and What It Means)?

The eating disorder field purports that an eating disorder diagnosis is much more common in women than men. The fact that the original diagnosis included skipped periods reveals that the diagnosis was created solely with women in mind and wasn’t very open to men having these disorders in the first place.

Early on my practice, I often would see men, young and old, for an initial appointment to discuss eating disorder symptoms only for them to never to return. The shame of admitting to the symptoms of what was deemed a women’s disorder was too strong to overcome. This fact may have changed to some degree, but the underlying belief that only women have eating disorders is intact.

Various media outlets, but especially social media, have made it increasingly clear that many men have eating disorders of all kinds. Just as with women, men experience symptoms which range from restricting food, obsession with low weights, binging and purging and excessive exercise. In fact, there is no discernible difference.

The only question is why eating disorders are still largely considered to be for women and why the treatment industry focuses almost exclusively on women.

The first component is that societal focus on body and weight remains much more interested in women’s bodies. Starting with the magazine industry prizing of thinness for women in the 1960’s, media continues to encourage women to base identity and success on their bodies. Some men feel the impulse to perfect their bodies and control food, but society bases a man’s success on many other things than body and weight.

Second, the coupling of life success and body image for women creates a dynamic that routinely disempowers even the most successful women. No matter how much women accomplish, they are burdened by the sense of failure and loathing about their bodies, encouraged to nitpick and drown in disgust at their physical selves. Men aren’t typically hampered by these external demands in the same way.

Third, the treatment industry and programs know that families will scapegoat and hospitalize their daughters much more easily than their sons. Societal pressures on families still values the expectations for success of sons over daughters, no matter how far feminism has changed our norms.

Financial firms which have bought and multiplied treatment facilities to amass insurance money know the profit lies with the treatment of women, who are much more likely to comply with enforced programs, repeat admissions and longterm care.

The next obvious question is why aren’t men with the same symptoms treated the same way?

This question reveals much less about actually clinical knowledge and research and much more about societal prejudice. Mental health treatment acts to disempower women now as it has for decades. The progression of illnesses created to reflect and enforce societal bias is ongoing for decades: hysteria, borderline personality disorder and now eating disorders span almost a century of psychiatric diagnoses.

These medical labels isolate and scapegoat a group of women and use clinical medicine to support the social order. That social order also includes the organizing principle that men are in power, even if they have what we call eating disorder symptoms.

Women in treatment programs need to be heard, not sequestered away. They need to be given a chance to grow and experience life, not languish in wards and centers meant to render them silent and impotent. They need to stop being seen as an impediment to our society and to be given a shot at life.

The treatment programs don’t work. All clinicians in the field know the success rate is low, but we have all been brainwashed into thinking it’s the only way to treat these patients, the large majority of them being women. Instead, we need to stand up and speak the truth so women who are scapegoated and isolated from the world get their due.

The Disgrace of Eating Disorder Treatment Programs

The last post attempted to distinguish between eating disorders and the deleterious and often traumatic effect of treatment. Clinicians often approach them as one issue, but time working with patients shows how different these two issues are.

The best place to start is to compare people with a longstanding eating disorder who have spent years in treatment to those who have not. With the explosion of private equity-funded programs, it’s harder to find people without any experience in treatment, but they do exist.

Those new to treatment have a much clearer path towards wellness. They need to be heard and to be understood as I explained in the last post. They need information about their eating patterns and how and why they have responded to food restriction over the years. They need guidance as to why this started and how to change it, if they want to. Last, they need to understand how their eating patterns are limiting and how to find what they want in life.

On the contrary, people who have spent years in programs have left behind all the original parts of their eating disorder. They are angry for having been locked up in programs, for having been treated like a child, for having been treated like a criminal, for being blamed for a problem as if an eating disorder is willful disobedience.

They are frequently obsessed with weight and calories because programs focus primarily on these factors. They want to manipulate their food to fight back against the system that has hijacked their lives for their own supposed good. They have lost hope on finding what they want in life and have internalized the idea that they are broken and have nothing left.

Treatment programs run by for profit financial companies intending to grow and sell a brand have little interest in healing anyone. Hospitals organized around the philosophy that eating disorders are a blemish on our society and need to be stamped out justify ostracizing an entire segment of people. Vilification of eating disorders pervades the broader social media world and allows people to blame this population for our own misguided obsession with food and weight.

Eating disorder treatment needs to focus on the individual first and foremost. These people, still mostly but not all women, feel unheard and unseen. In a culture that continues to idealize thinness, marginalized people fall into food restriction to seek out praise and attention. As I have written in this blog many times, the number one risk factor for an eating disorder is dieting. Many of the people looking for positive feedback by restricting food end up with an eating disorder and landing in punitive treatment.

Eating disorders are a cry for help from an isolated part of our society. We treat these people as the hysterics were treated years ago: blamed for their problems, locked up for their own good and punished until they give up any hope.

I feel so angry and powerless to make change despite treating this group of people for over two decades. I’m not sure what, but something needs to change.

Eating Disorder are About Not Being Heard

Eating disorder treatment is split between an academic and clinical focus. Research tends to look at assessment tools and perfecting diagnosis. The clinical treatment field is overwhelmed by the capitalist drive to turn a profit using health insurance payments. Individual outpatient treatment increasingly rests on virtual practices with clinicians limited in knowledge to treat people with eating disorders. The result is a wide ranging, disparate and unfocused way to help people looking for support and guidance.

Nowhere in this landscape is there a focus on the psychological and physical wellness of people seeking help.

People don’t get well using the criteria currently in vogue for assessment. So much of the focus is still on weight, daily judgment of food intake and regular threats of “higher level of care” when clinicians feel overwhelmed or frightened of a patient who doesn’t get better in a timely fashion.

People with eating disorders, for the most part, don’t feel heard or acknowledged in our society. They feel isolated and ostracized. They know they either need to fit into the box determined by external forces or be left on the sidelines.

The eating disorder, in one form or another, serves the purpose of getting the attention of those around them either by changes in their body or in their behavior. As much as treatment may be misguided and unwarranted, acknowledgement of the eating disorder expresses one’s displeasure and anger about the world in which they are trapped.

What is critical to note is that each individual does not choose this path. No one says they want to protest so they develop an eating disorder. Almost everyone falls into the eating patterns as a reaction to circumstances, experiences a beneficial physiological and/or psychological benefit and subsequently finds that they are trapped in the cycle.

Society is obsessed with thinness, so restricting food is encouraged in all communities, and these new eating patterns provide a form of expression that is otherwise ignored. Clinical research will show the genetic predisposition to eating disorders or the risk factors, but these data are not contradictory to the societal meaning eating disorders have in our world.

Attention to the individual person and their thoughts, feelings and desires can create a path for a meaningful life not lived solely through eating and weight. Similarly, opting for treatment which explicitly values the individual over food and weight will open a humane path for life to change and create a way for the person to learn to trust herself at the core.

Time and again, patients tell me that my belief in them and willingness to see them as an individual, no matter their eating patterns or weight, created the possibility for change. Ultimately, understanding people with eating disorders means understanding them fully. They are people suffering who only need someone willing to listen.

Body Image: A Symbol of Eating Disorder Treatment Gone Awry

One place to start addressing the effect of eating disorder treatment is the idea of body image. The inception of eating disorder diagnoses began with the cultural preference for thinness spread through mass media in the 1960’s and 1970’s. Classification and treatment incorporated the concept of body image as the bedrock of recovery.

Body image distortion conflated with body dysmorphia are now considered a hallmark for any eating disorder. The novel idea at the time that a person might not see their body as others do, or may in fact see a very different body, consumed the clinical eating disorder treatment world, but without nuance or creativity. It might have been helpful to consider how and why people struggled with self-image but wholly another to use body image as a way to disempower and confuse a cohort of young women.

Rather than see body image in a broader schema, treatment philosophy took the psychological experience at face value. Therapy attempted to force the person to renounce how they see themselves. Behavioral work encouraged people to do exposures to face what others considered the reality of their bodies. Therapists told people with eating disorders that they had distorted thinking about themselves and their bodies and did not truly know themselves.

However, cultural norms widely contradicted the messages from therapists. How could society value and reward thinness while treatment philosophy said the exact opposite? How could therapists seem focused on thinness themselves in their own bodies while simultaneously encouraging the people they treated to ignore the larger world completely?

The conceit of the eating disorder treatment field is to make the patient themselves feel confused if not crazy while ignoring the realities around them. In this context, eating disorder treatment appears to be almost conspiratorial, certainly not therapeutic. In no way can it be helpful to tell people not to trust themselves and learn who they are.

In this vein, the concept of body image distortion starts to have more nefarious connotations. It’s not a stretch to imagine that the mixed messages about body that women endure are intended to gaslight all women. Why should women gathering the power and momentum in all parts of our society be handicapped by the confusion around body image?

Inevitably, a substantial percentage of women succumb to these beliefs and are taken away from their own lives by years of treatment. The constant concern women feel about their own bodies reinforces the pernicious norms of self-blame and self-doubt.

I’m not sure where to take these ideas about body image in the larger scope of treating people with eating disorders. Some elements of treatment need to stand including helping people be nourished enough to live and not lose so much mental energy around food and body. I don’t believe women need guidance about how to see themselves or how to live. They certainly don’t need anyone telling them they cannot even see themselves clearly.

Anyone with an eating disorder needs help to find the path to be themselves and live the life they want. Too much attention on food, weight and body image distracts from the real issue, one that’s all too present in today’s culture: the subjugation of women through their bodies.

The Exploitation of our Youth through the Eating Disorder Diagnosis, Part I

The combination of the expansion of treatment programs and the effects of social media altered the meaning of having an eating disorder in our society.

These disorders first arose as a means for clinicians to understand the soaring rate of eating-related psychiatric symptoms starting in the late 1970’s and early 1980’s. Doctors scrambled to find ways to understand and treat people showing up in offices and at hospitals with often severe symptoms.

At first, treatment focused on hospitalization and stabilization of food intake and healing of medical symptoms. However, the lack of comprehension of how these disorders started led to an almost universal prejudice against these patients as entitled and often even feigning symptoms for attention. It was unfathomable that people would either not eat or binge and vomit unless it was volitional.

Over time, residential treatment programs, typically run by people who went through eating disorder treatment when they were younger, developed a feminist understanding to help young women find their own identity and direction in life. The philosophy was that young women were unable to find a voice in the world without action. Treatment focused on guiding women to find themselves in other ways with much more compassion and much greater success.

For a brief moment, treatment seemed like it might focus on the the real issue plaguing mostly young women seeking support and provide a community that would listen to them and validate their experiences.

The explosion of treatment centers funded by private equity ended the brief window of humane treatment and now cycles young people, women and more men, through therapy mills run by largely inexperienced clinicians and focused on reaping the reward of health insurance money.

Gone are the days of helping young people find their path in life. Instead, programs often admit people who don’t need inpatient care, cause trauma through harsh, ignorant treatment and only harden the need to find solace in other ways, largely through the eating disorder. Some programs may do good work at times, but the overall harm does not merit the few good experiences.

Social media is rife with people excoriating treatment programs and languishing behind the label of an eating disorder. These people feel blamed for their experiences, unable to find support for who they are and lost in a sea of societal scorn for their own true struggles. Ultimately, they are unable to find themselves or even find a place in the world to figure out who they are.

The deeper question is how did the eating disorder diagnosis and treatment become another means to satisfy capitalist greed? Where is the kindness and compassion for young people, still much more often young women, who are trapped in the chains of a destructive moniker? How does the eating disorder treatment field recover?

I’ll address these questions in the coming posts.

The Standard of Care for People with Binge Eating

In the last couple of years, many people seeking treatment for any binge eating (primarily bulimia, binge eating disorder or compulsive overeating) look to GLP-1 agonists medications as a way to cure their eating disorder. There may be a limited role for these medications in treating binge eating, but the mainstay of treatment is unchanged and often very successful.

Cognitive Behavioral Therapy is the central component of treating any binge eating disorder. The first step is logging food including the specifics of the meal, time of eating, whether it’s a binge or not and the thoughts and feelings around eating at that moment.

The process of logging has several key benefits: separation from the food to assess eating with more perspective, understanding the emotional and hunger cues that trigger binge eating and working together with the therapist to approach binging as a symptom that they can figure out together. Even more importantly, logging impresses upon the patient that there is a way to figure out how to stop binging.

Medications like Prozac and Topamax also play a role in decreasing binge urges but are a supplementary part of treatment rather than a cure. Working with a dietitian helps educate the patient about meal planning and the need for regular meals throughout the day to regulate hunger and fullness cues. Last, treating other concomitant psychiatric disorders, such as anxiety, depression and ADHD, makes stopping binging much more successful.

The new GLP-1 medications have confused the standard of care for binge eating. The lay concept of food noise in particular can push people with binge eating towards these medications. For laypeople, food noise means hunger caused by dieting and undereating. This new class of medication suppresses hunger for many people thereby making it easier to eat less in an unhealthy way and ignore hunger cues.

The term food noise describes very accurately the preoccupation with food that people with binge eating experience. It’s not a surprise that people with binge eating find this term validating; however, conflating food noise for someone with binge eating to food noise for someone without an eating disorder is problematic.

The biggest risk is that people with binge eating may think the GLP-1’s can cure their eating disorder and that food noise is a more universal symptom. The medications don’t treat binge eating on their own and almost always set people back who are in the process of treatment for an eating disorder and learning how to regulate their eating. Therapy and appropriate medications need to be the primary way to move forward.

The new GLP-1 medications have some limited use to treat people with binge eating, but the standard of care is very effective and must remain the first steps towards recovery. Food noise is a very apt description of thoughts around food for people with binge eating, but the term isn’t clinical and does not change how someone with binging can get better.

Don’t Blame the Eating for Everything!

Eating disorder thoughts typically weave into a person’s identity and feel inextricable from oneself. These disorders start at formative ages when identity develops. Other people react strongly to the eating disorder, only reinforcing the concept to a younger person that the disorder represents more than just a set of rules around eating but a way to define oneself. Often, the internal and external reinforcement create a profound identification with the essence of an eating disorder and leave little room for other forms of self-exploration.

Treatment feeds into this mythology by conflating the person and the illness. Unlike most psychiatric disorders, clinicians typically blame people with eating disorders for their illness and misconstrue difficulty following a meal plan with willful disobedience. For a young person trapped and confused in the mental maze of an eating disorder, blame for the illness confirms that this illness is who they are.

Attempts in treatment to separate the eating disorder from the person run through most plans for recovery. Therapy theories reflect the concept of the separation of the eating disorder voice from one’s own voice. Recovery refers to an ideal, a fantasy really, that life after recovery is idyllic once the eating disorder disappears.

In the process of this artificial definition of recovery, therapists in the eating disorder field often overlook one common theme for people with eating disorders: they don’t feel seen or heard. Being in a body approved or noticed by others or eating in a way that gets attention is the only way many people with eating disorders experience being seen. Take that away and they feel like they have nothing and are nobody. To the individual trapped in an eating disorder, getting better doesn’t feel like a choice.

The various treatment approaches using different types of behavioral therapy, meal planning, inpatient or outpatient programs or different types of trauma work are not likely to address the fundamental issue in eating disorder recovery. Each person struggling to move forward feels trapped behind the illness and all the ways they feel seen, access comfort and feel secure through the illness. In order to come out from behind that screen, therapy needs to focus on helping the person feel understood and heard and to learn who they are beneath the illness and treatment.

Each concern someone has can’t just be another eating disorder thought. Everything they feel can’t be fixed by eating more. All their life experiences can’t be the result of being stuck in an eating disorder.

Each person with an eating disorder has feelings, thoughts, preferences and ideas. Everyone struggling with an eating disorder is a legitimate person who needs to be treated as such.

Yes, clinicians can be concerned about the health and well-being of people with these illnesses because of the medical consequences in addition to psychiatric ones. The treatment team still has an obligation to remember this is a real person trying to get better from a real illness. Silencing them with endless blame for their daily experience in the illness only makes them sicker. Our job, first and foremost, is to listen.

The Best Course for Eating Disorder Treatment in the Current System

The plethora of treatment options and modalities obfuscate the clear and effective protocol to treat someone with an eating disorder. It’s too easy to get lost in all the ways to get help, yet what works hasn’t changed at all.

Various new programs and offerings create a confusing breadth of ways to consider treatment. Online partial hospitalization or outpatient programs, virtual team treatment, new supposed medication cures and even text therapy businesses make it hard for the newcomer to find a treatment path that can lead to recovery.

The combination of virtual mental health care that arose during the pandemic and the entrance of finance companies angling to capture some of the health insurance market share has put the health of eating disorder patients on the back burner.

Outpatient treatment entails a primary therapist well versed in the course of eating disorder recovery, not someone who dabbles in these illnesses, a dietitian knowledgeable about meal planning for eating disorders and also experienced with nutrition therapy and a primary care doctor to track any health concerns in the process. Sometimes a short-term group therapy or more specialized doctors are necessary. Psychiatric medications are often a part of treatment as well.

Choosing a team of providers with enough expertise to chart a course towards wellness is critical. In addition, recovery is a personal and emotionally intense experience; thus, patients need to prioritize finding clinicians with whom they feel safe and comfortable.

Because recovery is so hard, people unconsciously find ways to hide, and learning how to be open is an important part of getting well. Virtual work has become the norm for so many people, but it is very easy to hide behind a screen. At least for part of the treatment, meeting in person always benefits recovery.

When outpatient treatment isn’t sufficient, residential programs and hospital-based support are necessary. There are a handful of hospitals with experience treating people with eating disorders, and patients should seek this places out for optimal care. The landscape of outpatient programs has been transformed by venture capital funds. My recommendation lately is for shorter stays at residential centers, one to two months, during which patients put together an outpatient team for the transition back to their lives. Most residential programs are no longer set up for longer stays but instead help restore enough nutrition to do the true work at home.

Despite the changing eating disorder treatment field, I would advise patients seeking care to follow these guidelines. Ignoring the calls from well-funded companies luring people into their programs is wise. It still may take some work to find the best fit for each individual person, but the time invested is worth the outcome.

Eating Disorder Treatment After the Demise of Body Positivity

The onslaught of GLP-1’s in our culture has left the body positivity movement in the distant past and reignited the drive for thinness.

The growing movement of acceptance of all different body types, especially in women, had opened the door for new directions in eating disorder treatment. Body image distortion, the most persistent and stubborn symptom of any eating disorder, was a bit less powerful when the cultural acceptance of varied body types grew. People were more likely to consider different clothing sizes and less ashamed of the changes in their bodies that accompanies recovery.

The new class of medications promoting weight loss and the micro-economies around them spawned a renewed and even more powerful focus on thinness. People who never had eating disorders suddenly lost extreme amounts of weight. Influencers peddling body positivity suddenly showed up dozens of pounds smaller. Any variation in model body shapes vanished.

Amidst the about face in media images of women’s bodies, the eating disorder treatment world has backtracked greatly. Patients with all sorts of eating disorders, and in all shapes and sizes, gravitated shamelessly to finding any way to procure these drugs. Physicians and various medical-adjacent industries prescribed them readily, often with minimal or even no clinical indication.

The drive to find eating disorder recovery disappeared behind the promise of weight loss, minimal “food noise” (euphemism in the eating disorder world for any sign of hunger) and a magical cure for any eating disorder.

It has been harder as a clinician to encourage people down the emotionally challenging and time consuming journey of recovery. More and more people seek this new magical cure and are less likely to acknowledge and seek actual help for their eating disorder.

As the GLP-1’s lead to food restriction and potentially induce an eating disorder, even in those never sick before, I wonder what kind of devastation these drugs may leave in their wake. I have touted the potential uses of these drugs in recent posts because I don’t want to dismiss new, powerful drugs with clear medical benefit, but I am just as concerned about the negative outcomes.

My focus now is to acknowledge these new medications and recognize their benefit in manipulating the gastrointestinal hormonal system. However, the clinical community must also focus on eating disorder treatment that has not changed.

Clinicians who treat people with eating disorders need to stay true to treating this population. No medication has ever cured an eating disorder, and GLP-1’s are no exception. People who benefit from these drugs have already made headway in recovery. Eating disorder treatment entails the hard work of therapy, meal planning and food counseling with a dietitian and a long term process in order to help people get well.

The Use and Misuse of GLP-1’s for People with Eating Disorders

The new GLP-1 agonist medications are a live experiment due to the widespread use, and misuse, of these drugs. Here are my most recent observations and recommendations based on reviewing current research, communication with colleagues and clinical observations of patients with eating disorders.

First, the best approach to the medications is to start low and go slow. Some people even need to start at doses lower than recommended by the pharmaceutical company and often stay at very low doses. The benefits of the lower doses are fewer side effects, more longstanding benefit and time for one’s body to adjust to the metabolic changes. Going too fast leads to more side effects, especially nausea and constipation, which can build over months or even years and lead to necessary discontinuation of the drugs. The drugs work best when the intended use is for gastrointestinal hormonal imbalance.

Second, people on these medications need to have normal hunger cues and be able to eat regular meals. When hunger is suppressed, people end up restricting food and losing weight due to having less food than they need. This strategy is never sustainable as anyone knows who has an eating disorder. Food restriction leads to ongoing medical issues and rebound hunger, if not binging, thus perpetuating the binge and restrict cycle.

Third, the medications are ultimately hormonal in nature, not specifically weight loss drugs. They work by affecting hormones and adjusting how the gastrointestinal system works. At doses that are too high, they can lead to food restriction and severe weight loss with no long term benefit. The mentality one uses to approach the GLP-1’s is critical. They are medical interventions to be used judiciously, not miracle weight loss drugs.

Last, it’s very important that people with eating disorders don’t use these drugs to remain at weights lower than their body can manage. The end result is slower GI system, muscle wasting and many other effects of drug-induced anorexia.

These conclusions reflect my current understanding of the guidelines most useful for people with eating disorders considering GLP-1’s. There is no doubt these drugs are here to stay so a thoughtful, curious and cautious approach is necessary to use them safely. More information is on its way in the coming months.

The Existential Part of Eating Disorder Recovery

The expansion and monetization of eating disorder treatment has led to a primary focus on concrete steps and goals in recovery. Insurance companies demand practical goals for reimbursement, and the corporatization of treatment means less individualized care.

I believe strongly that behavioral therapy is a necessary component of early recovery and has a role in later stages as well. However, in the current jargon, full recovery indicates freedom from food and body thoughts without addressing the element of identity. If treatment doesn’t involve steps to separate oneself from the illness, it’s impossible to be free to live life fully.

Eating disorders encompass disordered eating, compensatory behaviors, body image thoughts and the all consuming experience of one’s mind being taken over by these demands. Recovery needs to help people find themselves beneath the all consuming nature of the illness.

Early recovery must normalize eating to insure one’s body gets the food it needs throughout the day while also minding the emotional and psychological turmoil that ensues. This part of getting well is always hard and is a necessary first step but is just that: a first step.

Treatment that began early in the eating disorder epidemic took the history of mental illness into account and recognized the existential component of treatment. Eating disorders grew out of the cultural imperative to be thin combined with the advent of mass media outlets spreading images of thinness throughout the country.

No one could predict the effect that sanctioned dieting combined with the idealization of thinness could have on a society. As social media made it easier to spread images and messages that propagate dieting and thinness, eating disorders have become endemic.

The nature of eating disorders and the media machine driving them necessitates a deeper dive into one’s identity for true healing. An eating disorder is now considered a widely accepted definition of identity in this culture. It’s easier than ever to eat well enough and be recovered while continuing to base one’s sense of self on the disorder itself.

An existential search for meaning can be painful at times. The work of therapy examines the core sense of oneself and reckons with the underlying thoughts of person, motivation and meaning. This exploration points the person in a direction of how to live life and what truly matters.

The process of pulling away from the safe identity of the illness and identifying the less sure but more genuine idea of being a full person allows someone to fully get well. Without the need for the eating disorder as a pillar of identity, there is much less reason for the eating disorder to linger.

If treatment ignores the key existential step in recovery, wellness simply means eating enough but still creating self around the empty meaning of food and weight. There has to be more to life than that.