When it comes to males with eating disorders, we have to do better—to reduce stigma, combat stereotypes and provide gender-sensitive treatment. Eating disorders can be lethal, but early intervention leads to better outcomes.

Unfortunately, males may underreport symptoms and seek help less frequently than females. They are also often missed by clinicians. These gaps come at quite a cost for males: Eating disorders have the highest mortality rate of any mental illness after opioid addiction. Depending on the study, research shows between 5 and 20 percent of those with an eating disorder will die either from the physical toll of the illness or from suicide related to dealing with it. And the risk of mortality for males with eating disorders may be even higher than it is for females, in part because they are often diagnosed later.

The most common is binge eating disorder, which is by far the most common eating disorder across all people. Binge eating disorder is almost equally distributed between males and females. After that, bulimia nervosa is more common in men than anorexia. That’s just the diagnosable eating disorders.

We also have all these males experiencing eating-disordered behaviors, which may not be diagnosable but still can cause a lot of damage. We estimate that about as many men are affected by subclinical eating disorders as by diagnosable ones. Clinicians refer to those as other specified feeding and eating disorders, which include purging disorder, night eating syndrome, and atypical anorexia nervosa, as well as binge eating disorders and bulimia nervosa that do not meet the diagnostic criteria in terms of frequency or duration of symptoms.

Lastly, boys may be at a higher risk than girls for avoidant restrictive feeding and eating disorder, which often shows up in childhood. ARFID, an eating disorder characterized by picky, rigid eating and an inability to meet nutritional needs, can interfere in growth and development—but unlike other eating disorders, there is no accompanying fear of weight gain or concerns about body shape or size.

Often an eating disorder is one symptom of other underlying problems.

Genetics and comorbidity: There’s typically a genetic component when somebody has an eating disorder—they tend to run in families—and there’s often a comorbid mental health condition. For males that often includes anxiety, depression, obsessive-compulsive spectrum disorder, or substance abuse.

The connection between eating disorders and trauma: If someone has been through something life-threatening to themselves or other people, they’re more vulnerable to being emotionally dysregulated. If a traumatic experience also had a physical component, a person may feel uncomfortable in their body and turn against it in the aftermath. Finally, shame is typically associated with trauma, which can lead to a desire to hide the self and quiet one’s voice. An eating disorder may develop as an attempt to cope with or avoid intense emotions, confront negative body image, and deal with memories of the past and fears about the future. And in those cases, treating the trauma would be key to healing from a co-occurring eating disorder.

This also applies when the trauma involves bullying. If someone has been bullied, that can have serious negative mental health consequences. We know from the research that at least half of those affected by eating disorders report that bullying contributed to the onset of their illness.

Cultural pressure and paradigms of masculinity: There is generally some aspect of cultural pressure having to do with the body. What exactly that is for any individual depends on what’s causing their obsession. For many men with eating disorders, because of the societal impacts of all definitions of masculinity, there’s some component of muscle dysmorphia. Muscle dysmorphia is a version of body dysmorphic disorder that’s focused on the size and definition of the musculature. Muscle dysmorphia may be an issue even if a person doesn’t meet the diagnostic criteria for body dysmorphic disorder.

“If how we look becomes such a big part of our self-esteem that it feels more like the hub of the wheel than a spoke on the wheel, our mental health becomes very fragile.”

Harrison Pope, Katharine Phillips, and Roberto Olivardia were some of the first people to start researching men with eating disorders. In their book, The Adonis Complex, they put forth the idea that in the late ’70s and early ’80s, the advertising industry started to target men by creating body insecurity for them the way it had already done for women. At the same time, we were seeing changes in who was defining masculinity in Hollywood—we went from a Clark Gable sort of masculinity, which was more defined by confidence, to a paradigm of masculinity that came from having a cut or ripped body. Steroids were becoming more accessible as well. And when this all happened, men and boys started to become even more uncomfortable in their bodies and started to believe that they would be more valuable if they changed their muscles and what they looked like.

Body dissatisfaction is linked to the development of eating disorders, and males tend to be more oriented toward muscularity and leanness—rather than thinness—when it comes to defining their body image concerns. Muscularity-oriented body image is often pursued through rigid dietary behaviors, meal timing, and muscle-enhancing supplements. These unhealthy and sometimes dangerous behaviors are promoted on promuscularity websites, online forums, and across social media platforms. The specifics of the “ideal” male body image have often been neglected in eating-disorder-prevention programs, assessment measures, and interventions, leading to clinical underrecognition and treatments that don’t quite fit. And eating disorders affect about one third of male athletes who participate in sports that emphasize physical appearance and weight class, such as bodybuilding, gymnastics, swimming, diving, wrestling, rowing, and horse racing.

Lack of emotional empowerment: We also have to take into account how we raise boys. Generally, we don’t prioritize helping boys develop a good understanding of their emotional lives and emotional needs. That’s problematic because when we need to cope with difficulties, it’s helpful to be able to describe what we’re experiencing emotionally. If we can’t articulate it, we’ll usually keep it to ourselves. Plus, we often do a poor job of teaching boys to value and put emotional trust in relationships to the degree that they need to in order to reach out to someone when they need help.

Although most males with eating disorders are heterosexual, gay and bisexual adolescents and men are more likely to engage in eating-disordered behaviors than their heterosexual counterparts. There is a greater risk for disordered eating pathology among sexual minorities who are transgender. Sadly, when we look at recent trends in the research, it is clear that this disparity is not improving. Sexual minority adolescents are more likely than heterosexual peers to engage in restrictive dieting, fasting, using diet pills, binge eating, and purging. Gay-identified college students are more likely than heterosexual students to be diagnosed with an eating disorder and to report dieting, using pills, or vomiting to lose or control weight.

Our thoughts, emotions, and behaviors start to meet the definition of a disorder when they impair our functioning. You can probably imagine why we are at increased risk for an eating disorder when self-esteem is defined by one factor, such as body image.

If how we look becomes such a big part of our self-esteem that it feels more like the hub of the wheel than a spoke on the wheel, our mental health becomes very fragile. When that’s the case, as it often is for people with eating disorders, the pursuit of a certain “ideal” body type might interfere with our health, happiness, relationships, career, and other values.

Eating disorders are inherently isolating, regardless of gender. The symptoms themselves cause a lot of shame, and people with eating disorders often try to hide them, which involves a degree of self-isolation that can kick-start a cycle.

Here’s an example: This person’s self-imposed isolation, driven by their shame, makes them feel bad that they don’t have as many friends as other people. They might look around and think, Oh, what’s wrong with me? Why don’t I have more friends? That fuels the belief: Maybe if I change my body I can be better accepted. And then it fuels the eating disorder, which further fuels the secrecy and isolation.

One of my clients, an expert by experience, asked me to share his story: “For me, warning signs were varied but began occurring very close together. One was a notable dip in my desire to hang out with friends. It was a negative feedback loop: I would choose to be alone and then feel angry because of it. Another sign was increased irritability toward my parents, particularly when my eating habits would come up. I would feel ashamed and vulnerable when it was brought up, which made me immediately defensive. The warning signs were all unpleasant. I tried to ignore them, thinking they would go away.”

“There are so many ways that these illnesses can be isolating, so having a safe haven with people who love you makes it a lot easier to stick with treatment and work on recovery.”

For men, there’s often less tolerance of vulnerability. The broader cultural idea of what it means to be masculine and strong can interfere with their willingness or ability to describe vulnerable moments and vulnerable situations, and it can interfere with their capacity to reach out for help.

Part of why men often don’t tell anybody about their disorder is because of the perceived stigma of having a “female illness.” Of course, it’s actually not a female illness at all. Twenty-five percent of people with eating disorders are men. The rate at which men were hospitalized for eating-disorder-related causes rose more than 50 percent between 1999 and 2009. That’s a sign that more men are reaching out for treatment, but it doesn’t mean we’re breaking down the associated stigma. Often when adult men come in for treatment for an eating disorder, they don’t tell their family or friends. They tell only the treatment provider.

There are some common risk factors for developing an eating disorder: perfectionism, anxiety, depression, body dissatisfaction, history of dieting, history of trauma, being a victim of bullying, having a close family member with an eating disorder (or the history of one), and having few social connections.

One warning sign of an eating disorder is when someone finds themselves locked in a bubble of secrecy. They’ll often start lying to people in their life or missing valued events because of insecurity, shame, fear of eating, fear of overeating, or a desire to hide that they’re restricting eating.

“Eating disorders thrive on lies.”

Eventually those behaviors catch up to them. When that happens, the hope is that their family will approach them with love and support. However, it’s often the case that family and friends start to catch their loved one in these lies and don’t know that the root of it is an eating disorder. So there’s a huge misunderstanding about why this person is lying—and then it can be misconstrued that they might be narcissistic or don’t care about their relationships with other people.

But really, it’s that eating disorders thrive on lies. People often keep their eating disorder behaviors a secret. So if we catch people lying about risky, maladaptive eating or exercise behaviors and wonder if it’s because they have an eating disorder, it’s important to come toward them with compassion instead of at them with confrontation.

In all cases, anyone with an eating disorder should be assessed by a primary care doctor or a pediatrician and a therapist who specializes in treating eating disorders. After a full assessment, a recommendation will be made about whether hospital-based intervention is necessary. If they are medically stable, there are a variety of treatment options. For children and adolescents with eating disorders, family-based therapy is one of the most effective treatments. In FBT, therapists serve more as coaches helping empower caregivers as they take charge of food and exercise until those can be turned back over during recovery. Sometimes working with a doctor, therapist, dietitian, and psychiatrist in coordinated outpatient treatment is best. And in other situations, people with eating disorders benefit most from residential, partial hospitalization or intensive outpatient treatment. Due to the medical and psychiatric risk—and high mortality rate—of eating disorders, it is essential to start with a comprehensive evaluation.

Having an eating disorder is torturous: It torments the mind because a lot of the time, and especially with anorexia nervosa, the eating disorder tells you that you want the disease. That makes it even harder to fight. There are so many ways that these illnesses can be isolating, so having a safe haven with people who love you makes a lot easier to stick with treatment and work on recovery. It takes a lot of love, encouragement, support, nonjudgment, acknowledgment of the medical and psychiatric seriousness and understanding. Those things do help.

Even though males don’t get diagnosed or show up for treatment as often as females, once they do show up for treatment, they’re as likely to get better.

The National Eating Disorders Association is a good source of information, and it has a module on its site where you can look for treatment centers. What’s notable about this function is that there is a box you can check to search specifically for centers that accept men—not all treatment centers do. NEDA is based in the United States.

The Academy for Eating Disorders is an international organization, and it’s an excellent resource as well.