2. Preview
Clinical treatment of gay men with eating
disorder symptomatology is a unique
challenge. These men are considered dual-
minorities as they are neither heterosexual,
nor the typical female eating disorder client
which is the current paradigm for eating
disorder treatment. We wish to provide the
reader a solid foundation in understanding this
unique population of clients through case
conceptualization and treatment suggestions.
3. Why is this a special clinical
issue?
The prevalence of eating disorders in all men is
rising and more men are seeking help for their
eating disordered behavior and are being
identified as needing treatment (Strother,
Lemberg, Stanford, & Turberville, 2012).
Gay men have higher rates of eating disorders
than heterosexual men (Brown & Keel, 2012).
Homosexuality puts men at more of a risk for
developing an eating disorder (Morgan, 2008).
4. Why is this a special clinical
issue?
Treatment paradigms have been focused on
women and girls, while stereotypes about ED
inhibit evidenced-based treatment modalities
for men (Morgan, 2008).
Gay men living with ED hold a dual-
marginalized status and are thus vulnerable to
additional health and metal health issues.
5. Eating Disorders (ED)
Eating disorders are abnormal eating habits that
threaten your mental and physical health. The
three primary disorders are:
Anorexia nervosa: Individuals believe they are
overweight even when they are dangerously
underweight and restrict their eating to the point of
starvation.
Bulimia nervosa: Individuals eat excessive amounts
of food, then purge by making themselves vomit,
using laxatives, or over-exercising.
Binge eating: Individuals have out-of-control eating
patterns, but do not purge.
(American Psychological Association, 2015)
6. Prevalence rates
25% of anorexia and bulimia cases are males
(Hudson & Pope, 2007).
Over one million men struggle with ED (National
Institute of Mental Health, 2008).
ED behavior increases 10 times more in gay men
than heterosexual men (Strong, Williamson,
Netemeyer, & Geer, 2000).
Lifetime prevalence rates for men: anorexia 0.2-
0.3%, bulimia 0.1-0.5%, and binge eating disorder
1.1-3.1% (Raevuori, Keski-Rahkonen, & Hoek,
2014)
7. Prevalence rates
Men with “undifferentiated” or “feminine”
gender roles in the gay community have a
higher prevalence of ED than more
“masculine” or “androgynous” gay men
(Strother, Lemberg, Stanford, & Turberville,
2012).
8. Clinical considerations
Why is this population susceptible to ED?
The media:
Higher rates of body surveillance and the media’s
objectification on male bodies may contribute to the
pressure for gay men to fit a physical ideal. The
media also contributes to disordered eating and
depression (Dakanalis et al., 2012).
Furthermore, this objectification has been linked to
greater body managing and body shame.
9. Clinical considerations
Ageism and Masculinity:
According to a study conducted by Boisvert and
Harrell (2009), overall a thin, muscular physical
appearance is considered more ideal for younger than
older gay men, which puts younger gay men at a
greater risk of developing ED.
Furthermore, higher rates of body shame related to
the expression of masculinity is a prominent indicator
of disordered eating among gay men, with the next
dominant indicator being BMI (Boisvert & Harrell,
2009).
10. Integrated etiology &
comorbidity
When treating ED in a gay male client,
comorbid disorders often present themselves
(e.g., mood disorders, anxiety disorder,
substance abuse, impulse-control, and past
trauma)
Depression is among the most common comorbid
diagnosis with eating disorders (Tan Shian et al.,
2014).
Anorexia often co-occurs with Body Dysmorphic
Disorder (Didie, Reinecke, & Phillips, 2010).
Some disease models look at eating disorder as a
piece of Obsessive-Compulsive Personality
Disorder (Cooper, 2009).
11. Comorbidity factors
Fact: Rates of psychiatric comorbidity are higher
among men than women (Raevuori, Keski-
Rahkonen, & Hoek, 2014).
Why? One theory is that males, especially gay males,
are more susceptible to “double stigma” or the stigma
of having both a psychiatric disease and also an ED
which is most commonly associated with women/girls
(Raisanen & Hunt, 2014).
Excessive exercise and athletic achievement are
highly regarded features among men and there is a
sense of competiveness in the gay community in
regards to these expectations (Raevuori, Keski-
Rahkonen, & Hoek, 2014).
12. Treatment
First – What is best for my client? What
contextual factors are at play here?
When thinking of a treatment to use it may be
best to include treatment that is gender-sensitive
as well as LGBT-affirmative (Greenberg &
Schoen, 2008).
It may also be valuable to discuss the role of
societal influence on masculinity and the “ideal”
male body(Greenberg & Schoen, 2008).
Age, SES, religion, systems of support, etc. are
all important contextual factors to assess for.
13. Treatment
Modality
Cognitive-Behavioral Therapy has been used
successfully to treat gay male clients who are
suffering from eating disorders (Greenberg & Schoen,
2008).
CBT addresses the cognitive distortions associated with
body shaming and dealing with perceptions of what the
"ideal" male should be.
Narrative Therapy has been successful with
numerous other populations living with ED (Weber,
Davis, & McPhie, 2006).
NT is a post-modern approach which acknowledges the
influence of dominant discourse and society on the stories
of marginalized individuals.
14. Case formulation:
Interpersonal relationships
A common factor in the development of eating
disorders in gay men is relationships.
Having an unsatisfying romantic relationship, or no
romantic relationship at all, was a key predictor in
developing a “drive for thinness” and eventual eating
disorder symptoms. This effect was significantly
greater for gay men than it was for heterosexual men
(Brown & Keel, 2015).
The dating scene—especially online—is often filled
with “no fatties” requests and other body-shaming
remarks, which have driven gay men toward
dangerous efforts to please each other (Dilts, 2011).
15. Case formulation:
Interpersonal relationships
Support exists for many gay men who prefer
larger body types (e.g., Bears) but these
groups are a minority within a minority, and are
unlikely to be found in most gay communities
(Whitesel & Shuman, 2013).
16. Case formulation:
Intrapersonal relationships
The stress and internalized shame that
comes from being in a minority group often
manifests in eating disorders among gay men
(Walloch, Cerezo, & Heide, 2012).
Internalized homophobia is often present in gay
men with eating disorders (Ballantyne, 2012).
Body image dissatisfaction is more closely linked
to eating disorders in gay men than in
heterosexual men, and is a primary predictor of
developing eating disorders (Yean et al., 2013).
17. Case formulation:
Clinical caution
Men, especially gay men, often present with
symptomatology that deviates from common
eating disorder stereotypes and observations
(Bosley, 2011).
Not all eating disorder cases are meant to be
formulated from a raw social pressure
perspective; sometimes the underlying factors
have more to do with medical attitudes than social
ones (Cooper, 2009).
Example: A gay man told by his physician that he has
a wheat allergy may respond by periodically starving
himself and punishing his own body for its failure.
18. International research
In a Singaporean study, most gay men with
eating disorders reported having obesity
before developing an eating disorder, and
having exercise habits that were “excessive”
by medical standards (Tan Shian et al., 2014)
In a study of Latino gay men, predictors for
developing eating disorders included alcohol
abuse, body image, depression, self-esteem,
and sexual behaviors (De Santis et al., 2012)
19. International research
A study of Italian men with eating disorders
showed that there was significantly increased
objectification (seeing your own body as an
object that should attract others) and body
shame in gay men than in straight men
(Dakanalis et al., 2012)
