Gendered Considerations in the Treatment and Prevention of Eating Disorders

Margo Maine and Douglas Bunnell

Advances in the study of the genetics and neuroscience of eating disorders (EDs) threaten to marginalize considerations of the social and environmental factors that contribute to the etiology and maintenance of these complex conditions. Over the past decade, the EDs field has trended toward reductionism and biological determinism, significantly narrowing the scope of treatment and prevention models. In our opinion, however, any attempt to develop a meaningful conceptualization of EDs requires a biopsychosocial approach, carefully considering the many different factors that confer risk and vulnerability. Gender is only rarely mentioned in the current treatment or research literature, but it is, in fact, the most powerful risk factor for the development of an ED (Striegel-Moore & Bulik, 2007). In this chapter, we examine some of the ways in which gender still matters when considering how to prevent and treat women and men with EDs. Specifically, we review how gender development affects the risk for EDs, explore the role of sexualization and objectification, provide a brief overview of current perspectives on the gender-based factors that maintain and reinforce eating pathology, and begin to address some of the gender differences in the clinical features of EDs. We conclude with our view of how gender-informed clinicians can best work with their male and female patients with EDs.

Scope of the Problem

EDs, disordered eating, and body image dissatisfaction are ubiquitous and debilitating. Now the third most common illness in adolescent girls (Fisher et al., 1995), after diabetes and asthma, EDs are a major public health issue, appearing in every strata of U.S. culture and, as a result of globalization, in more than 40 countries worldwide (Gordon, 2001). Although multiple pathways may lead to an ED, virtually all involve a common factor: dieting. The act of dietary restriction can, for vulnerable men and women, be profoundly destabilizing. A recent survey in the United Kingdom found that nearly 25% of children younger than 10 diet and think they are overweight, with nearly 30% reporting dietary restriction. Nearly 50% reported that they had been teased and bullied about their weight and shape (Bates, 2012). Body image concerns, weight preoccupation, dieting, and weight- related teasing and bullying all increase the risk for EDs (Neumark-Sztainer, 2005). Also, although many people still consider EDs to be relatively benign problems of choice, the truth is abundantly and tragically clear. EDs are the most lethal illnesses with the highest rate of premature death of any psychiatric diagnosis (American Psychiatric Association, 2000; Sullivan, 2002). Even at the milder end of the clinical spectrum, these insidious disorders wreak physical and emotional havoc. For many women, and for an increasing number of men, weight, shape, and body image concerns are the sources of profound anxiety, self-criticism, and self-loathing that barely soften across the life span. Women in their 60s and 70s are as prone to the same levels of body image dissatisfaction as younger women (Lewis & Cachelin, 2001; Maine & Kelly, 2005).

Although EDs are not the only gendered psychiatric condition, the degree of gender disparity is much greater than with most diagnoses (Levine & Smolak, 2006). Past research has consistently found anorexia nervosa (AN) and bulimia nervosa to be 10 times more prevalent among females than males and binge eating disorder to be 3 times more common (Treasure, 2007). A national survey of psychiatric comorbidity reported that nearly one quarter of diagnosable cases of eating pathology occurred among males (Hudson, Hiripi, Pope, & Kessler, 2007), a substantial increase over other estimates of male prevalence. Men are clearly demonstrating increased body image concerns and more pressure to look young and competitive in contemporary society, so they may be more drawn to disordered eating and related behaviors. A substantial minority of men in the general community have significant levels of disordered eating and compensatory behaviors (Striegel-Moore et al., 2009). Yet, even with data suggesting an increase in EDs among males, the overall gender disparity remains pronounced. Gender plays an important role in shaping weight control attitudes and behaviors, and thus the prevention and treatment of EDs requires a thoughtful and nuanced appreciation of its influence.