The enigma of male eating disorders: A critical review and synthesis (Murray et al. 2017)

The above titled article is newly out in Clinical Psychology Review. Here, I present a cursory analysis of the review and its significance.

Here is the abstract:

Historically, male presentations of eating disorders (EDs) have been perceived as rare and atypical – a perception that has resulted in the systematic underrepresentation of males in ED research. This underrepresentation has profoundly impacted clinical practice with male patients, in which i) stigmatization and treatment non-engagement are more likely, ii) a distinct array of medical complexities are faced, and iii) symptom presentations differ markedly from female presentations. Further, the marginalization of males from ED research has hindered the assessment and clinical management of these presentations. This critical review provides an overview of the history of male EDs and synthesizes current evidence relating to the unique characteristics of male presentations across the diagnostic spectrum of disordered eating. Further, the emerging body of evidence relating to muscularity-oriented eating is synthesized in relation to the existing nosological framework of EDs. The impact of marginalizing male ED patients is discussed, in light of findings from epidemiological studies suggesting that clinicians will be increasingly likely to see males with ED in their practices. It is suggested that changes to current conceptualizations of ED pathology that better accommodation male ED presentations are needed.

I have to admit a scholarly bias here (as opposed to personal bias – I don’t know him at all. Whilst this review is clearly a team effort (most of the writers are key researchers in the world of ED), I already really rate Murray’s work and follow it closely. This is for two key reasons: A) he’s quite prolific, so anyone working in this field would be remiss not to make sure they critically analysed his publications for inclusion in their own syntheses. B) His analyses and associated findings are thorough.  As such, I’ve learnt a good deal from reading his work (and that of his colleagues, it’s fair to say). If you are beginning to study male eating disorders for a master’s or doctorate, you should be adding this to your list of material to read first.

 

An authoritative synthesis

So, all subjective disclosures aside, I have some observations, thoughts and questions that arise from my reading of the article.

  1. I found the information on prevalence far more digestible and considered than in some previous literature I’ve mined. Indeed the old ‘10% of cases’ figure was referred to as a somewhat historic ‘rule of thumb’ – good as clinicians and scholars we need to be exposing these inaccurate, over-simplifications for what they are, irrespective of how media-friendly they can be.
  2. I find that the emphasis on the ‘marginalization’ of males resonates heavily with the non-generalisable findings from my own qualitative research (post-PhD publication is in progress, so watch this space).
  3. The paper’s thrust is clearly to further the inclusion of muscularity-related findings in the ED canon of research, rather than placing it with the dysmorphic diagnoses.
  4. I feel intellectually validated. Everything I wrote in my doctoral thesis that had previously been under-asserted in psychiatric literature is laid bare here for the reader to think about. Examples are:
    • observations about the nosological flaws;
    • issues between men and women when it comes to what constitutes bingeing;
    • muscularity and bulk and cut cycling as a male-inclusive gym discourse;
    • the disquieting and as yet unexposed enormity of BED (I predict this will be the ED issue of the next century);
    • inclusion of the role of excessive/compulsive exercise when it comes to men.
  5. The review convincingly achieves what I too strove to show: that taking a narrow, overtly indexable take on male eating disorders is flawed. We need to be taking into account men’s bodies, their muscles, their masculinity into account – in order to change the face of mental healthcare and treatments, men will be helped by experts who see beyond the immediate symptoms in a diagnostic manual.
  6. It managed to avoid all glib and amorphous mentions of the role of ‘media’ in men’s eating disorders. Thank goodness. This is often slipped in without any due examination and ends up being little more than an afterthought. Even studies that investigate media and EDs fail to: A) adequately account for the fact it is a plural concept, not a unitary entity; and B) convincingly articulate a nuanced and complex tapestry of the intersections of self, psyche, embodiment and so-called ‘media’. Bordo does a better job of this than most psychiatric studies.
  7. It incorporated some of the limited qualitative findings we’ve seen more recently – these are vitally important and should not be overlooked – yet they frequently are, in reviews designed for a clinical audience.
  8. Finally, and really this should form part of the list in #4 above, …fanfare please… At last a clinical paper that uses vital word count to point out something that often is left un-articulated within male ED reports, and that is oft-assumed, unquestioned, in sexual orientation studies: “Sexual orientation is associated strongly with gender conformity, yet it is not a complete proxy for gender expression” (p.6). Forgive my next un-academic statement: I am sick and tired of psych papers conflating sexual orientation, gender and biological sex – as if all these things were entirely interchangeable and were not subject to societal as well as psychological interpretations. My info-jammed brain did a little leap of joy when I saw that line. And this leads me to the following thoughts/questions.

 

However…

Murray et al. are necessarily limited to the inferences they can draw based on the literature as its evidence-based. This means that there are some assumptions that accompany some of the positives above:

  • Emerging, divergent and non-traditional ideas of male body ideals are unaccounted for. What about we men who are disinterested in muscularity, yet cannot bear the notion of striving for thinness? Is there no research at all on this?
  • Sexual orientation was covered but actual sexuality was not, yet there is modest evidence in of the role of sex in the development of EDs in cisgendered, heteronormatively influenced men – not even in section 11, where implications could have been pushed further.
  • Masculinity appears but – as always happens out of necessity – it appears in the singular – this is despite the overwhelming evidence that there’s really no such thing – only masculinities in the plural. Men around the world are not in possession of a singular masculinity as a unified construct – a significant failing of psychiatry.
  • The psychosocial features but fails to linger. This is a pattern found in the bulk of male ED research. It’s as if we accept ‘oh, yeah, there’s psychosocial stuff’, maybe a list a few factors – at best give a quick illustrative paragraph and then it’s one to measuring men for risk indicators etc. I struggle to believe that exploring the psychosocial can be distilled to analysing set of ‘correlates’.
  • Ultimately, I suppose that as a sociologist who blurs the lines into philosophy and social psychology of male eating disorders, it’s my job to tackle what psychiatry is ill-equipped to do. Give a societally grounded exploration of the phenomena implied by these last 4 bullet points.
  • I’m left with these questions:
    • What is the nature of the ‘compromised masculinity’ that is mentioned? how is this defined? by whom?
    • If men fit ready-labels less than women, how do we capture meaningful data on what is happening to them when they are in the middle of disordered eating?
    • If, as this research proves, we continue to study men in ways limited by medical methods, how do we solve the social issues raised in this paper? (e.g. muscular body ideals)
    • There’s little ’empirical evidence bearing on the male experience of BN’ – how can this be addressed?
    • Interdisciplinary research is the zeitgeist in many sciences in UK research – when will the world of MED embrace this, and bring together radically different disciplines to solve key problems? Why can’t a psychiatrist, a sociologist, a public health specialist and an anthropologist look at these issues together?
    • When will the male voice and the male experience finally equal the voice of clinicians in determining what questions we ask and how we learn more about what men need?
    • Where is the masculist research to investigate male EDs, the way feminist research has tackled female EDs? (N.B. – there is a vast difference between masculism and masculinism!)

I’m not at all suggesting that this one review should have answered all these questions – I’m just showing that we need more and more of this work – to leave no stone unturned in the battle for better experiences for males.

 

Final evaluation

This is an essential read for those working with, and researching, men with eating disorders.

 

Murray, S.B., Nagata, J.M., Griffiths, S., Calzo, J.P., Brown, T.A., Mitchison, D., Blashill, A.J. and Mond, J.M. (2017) The enigma of male eating disorders: A critical review and synthesis. Clinical Psychology Review. 57, pp.1-11.