Introduction
Eating disorders (EDs) are complex mental illnesses impacting widely on biopsychosocial spheres of people’s lives (NEDC, 2017). EDs do not discriminate between age or socioeconomic status (Hay et al., 2015; Smink et al., 2012) and while gender is an important factor, society is slowly moving towards gender equity for understanding gender-specific presentations of EDs (Bunnell, 2010; Hay et al., 2015). There is a trend of clinicians and services seeing an increase of male clients with EDs (Bunnell, 2010; Thompson, 2017). Regardless, research reveals a female dominated understanding of EDs and interventions fail to meet the needs of men (Drummond, 1999; Raisanen & Hunt, 2014). Banker and Klump (2010) describe a research-practice gap; important new research findings are not applied in practice by services or practitioners in the ED field which has wide reaching consequences for men. This paper discusses and analyses social factors influencing men with EDs in Australia, including current public health responses. It is concluded strategies need to be implemented to bridge the gap between research-practice in Australia and this will be supported by evidenced based public health response recommendations.
Social Distribution and Production
The National Eating Disorders Collaboration (NEDC) states approximately 9% of the Australian population are affected (NEDC, 2017). Approximately 25% of those with Anorexia Nervosa (AN) and Bulimia Nervosa (BN) are male and 50% for Binge-Eating Disorder (BED) (NEDC, 2017). Dearden and Mulgrew (2013) found ED practitioners reported working with only 1-3 men in the previous year. The risk of premature death is increased for anyone diagnosed with EDs and the mortality rate of 20% is the highest of all psychiatric illnesses (NEDC, 2017). Approximately 97% of people with EDs have a comorbid mental illness; the most common being mood disorders of depression or anxiety (NEDC, 2012). EDs are not only confined to western countries, research reveals they have a global distribution but this is difficult to ascertain as low-income countries have sparse epidemiological data (Hoek, 2016). It is important to acknowledge however, the idealisation of body type and appearance is predominantly a ‘western culture’ influence which has significantly contributed to the development of EDs (Miller & Pumariega, 2001).
There is evidence socioeconomic factors and inequalities are not significantly associated with the distribution and production of EDs in Australia, although economic status does impact people’s ability to access support and treatment (Hay & Mitchison, 2014; Hay et al., 2015; Gibbons, 2001). However, research emphasises specific groups of men are more at risk including those participating in competitive sport or exercise, young men, and the LGBTIQ community (Pereira & Alvarenga, 2007; Weltzin, et al., 2005). Studies of the onset of men’s EDs found this occurs most commonly for University aged men and is correlated with highly levels of body dissatisfaction and self-objectification (Dakanalis et al., 2016; Ousley et al., 2008). Studies on western countries, including Australia, reveal homosexual and transgender men are more vulnerable and there is a high correlation between EDs and body dissatisfaction and peer pressure in this group (Hospers & Jansen, 2005; Russell & Keel, 2001). LGBTIQ males are more likely to struggle with body image issues due to the overemphasis on the importance of physical appearance in these communities (Duggan & McCreary, 2004; Hepp & Milos, 2001). Lastly, men who participate in competitive sports or exercise are more at risk, likely due to sporting environments and ‘sport culture’ reinforcing ideal physical traits and encouraging negative eating behaviours (Petrie & Rogers, 2001; DeFeciani, 2015).
The social production of EDs is complex and multifaceted (Polivy & Herman, 2002). It is difficult to identify these factors specific to men as the majority of literature and clinicians experience is limited to women (Bunnell, 2015). Bunnell (2015) and Miller and Pumariega (2001) argue social construction of gender and masculinity influences how men consider their physical appearance, experience their bodies and their physical and emotional needs. Media and sociocultural representations of the ‘ideal male body’ have changed and recently become highly visible in modern society (Burlew & Shurts, 2013; Polivy & Herman, 2002). Burlew and Shurts (2013) argue men become critical about themselves and internalise these images and pressures. Duggan & McCreary (2004) and Neumark-Sztainer (2014) state men, unlike women, focus less on thin body ideals and more on muscle definition and leanness. Research indicates a range of factors contribute to the development of EDs, including traumatic or challenging family environments, experiences of bullying, the trait of perfectionism and familial genetics (Polivy & Herman, 2002; Bulik et al., 2003; Patterson, 2007; Hoek, 2016). It is likely a combination of these factors contribute to the development of an ED in an individual male (Polivy & Herman, 2002).
Social Construction and Perception
Though men have struggled with eating issues for centuries, the social construction and perception of EDs is predominately a ‘female illness’ (Paterson, 2008; Lock, 2009). This is likely due to the large numbers of women presenting with EDs in comparison with men and women have predominately been the focus of physical appearance pressures (Maine & Bunnell, 2008). Maine and Bunell (2008) argue globalisation and modernisation resulted in men being subjected to and confronted with media images of the ‘ideal body’. With the social perception of EDs as a ‘female issue’, men who speak openly about EDs are perceived by others as ‘feminine’ or, for heterosexual men, as ‘gay’ (Paterson, 2004). Men have been invisible within ED research and literature in Australia for a long time; only recently have they built a small niche of studies (Greenberg & Schoen, 2008; Paterson, 2004).
As a result, there is a significant lack of knowledge about men with EDs and the serious health problem it presents (Dearden & Mulgrew, 2013; Peate, 2012). This extends to men who have difficultly recognising ED behaviours in themselves (Paterson, 2004; Peate, 2012). While this issue is highly specific for men, there are many misconceptions about EDs in Australia regardless of gender (Crisp, 2005; NEDC, 2010). EDs are socially perceived as being about vanity, ‘dieting gone wrong’, a choice or a cry for attention and as ‘a phase’ of adolescent girls (NEDC, 2010; Griffiths et al., 2015). Men with EDs not only deal with this general stigmatization but struggle with added gender misconceptions and discrimination (Murakami et al., 2016).
Social, Cultural and Political Impacts on Men with EDs in Australia
Gender inequality in health can be harmful for men, as well as women (Sen & Ostlin, 2008). The small niche of research on men’s experiences of EDs demonstrates there are significant social and political impacts, particularly as a result of social misconceptions and stigma. Ahonen (2003) and Wooldridge et al. (2014) found men with EDs suffer from a sense of shame and fear and struggle with isolation and alienation. Men with EDs report greater self-stigma about their issues and the need to seek psychological help (Griffiths et al., 2015). Men to frequently delay seeking help, resulting in an increased likelihood to be undiagnosed and have longer duration of symptoms (Griffiths et al., 2015). The numbers of men seeking support from ED practitioners or services are extremely low in Australia (Dearden & Mulgrew, 2013). Men who have received support state they experience being a minority in services and feel like ‘intruders’ in female-focused groups (Dearden & Mulgrew, 2013; Drummond, 1999). This negatively influences the government funding allocated for these services and financial gain of professionals and thus, this public health issue is low on the political agenda in Australia (NEDC, 2012).
Analysing the Responses
Responses of Men with EDs
Men have voiced they are wanting gender-specific services and information for EDs in Australia (Dearden & Mulgrew, 2013; Wooldridge et al., 2014). Dearden and Mulgrew (2013) found all male participants expressed interest in gender-specific support groups or group therapy programs. Wooldridge et al. (2014) found men are frequently seeking gender-specific information and support online. Unfortunately, the majority of men with EDs remain unheard, unseen and misunderstood in the Australian community due to stigma, isolation, shame, fear and a lack of knowledge (Strother et al., 2012; Drummond, 1999).
Service Provision
Men have reported receiving negative responses from service providers in Australia. NEDC (2011) found people of all genders reported frontline professionals, including GPs, do not understand or have informed knowledge of EDs. Studies conducted in Australia and America support this finding; being male is strongly correlated with having an undiagnosed ED and not being referred by a medical practitioner for an ED consult (Griffiths et al., 2015; MacCaughelty et al., 2016). All ED services in Australia are predominately ‘feminized’ and their programs are founded upon female experience and directed toward female clients (Dearden & Mulgrew, 2013; Drummond, 1999). As previously mentioned, the service provision response in Australia to this issue is hindered by the research-gap gap (Banker & Klump, 2010), low political priority and limited funding (NEDC, 2012).
Current Public Health Response
Australia’s public health response has been limited and this is likely due to the apparent uncertainty of which governing body and clinical system should be responsible (NSW Health, 2013). In 2009, the Australian Government initiated and funded NEDC in an attempt to collaborate with people with EDs, researchers, ED experts, health administrators and the media to develop a framework for the prevention and management of EDs on a national level (NEDC, 2012). NEDC has developed and published ‘An Integrated Response to Complexity: National Eating Disorders Framework’ in 2012, which is the first national schema for EDs in Australia (NEDC, 2012). Outside of this framework, there is currently no formal national ED policy in Australia or in the states and territories. ED’s are currently covered by key mental health policies, particularly the Fourth National Mental Health Plan (2009), however they are not a key focus nor are ED’s distinct nature, complexities and unique issues discussed and addressed (COA, 2009).
Further Research and Information Required
An analysis of each Australian state or territory and their individual public health response to the issue of EDs is required. This includes research into how or if they have each responded to the NEDC 2012 National Framework and any future plans or policies being developed. As this paper focuses on a national perspective, this was not included. Furthermore, the small niche of Australian studies on men’s experiences of EDs is extremely underdeveloped and it is recommended further studies are funded to build upon this knowledge. This includes studies focusing on bridging the research-practice gap and assisting services to implement gender-specific interventions, as this is an evident literature gap. Allowing men with EDs a voice in this research would improve the relevance and effectiveness of data gathered.
Proposed Public Health Response
The NEDC 2012 Framework was a positive step towards developing an effective approach to this issue. However, a comprehensive and holistic public health response needs to extend beyond this. There is empirical evidence which can inform specific targets and direct response efforts. These targeted priorities and goals are outlined below using the framework presented by Turrell et al. (1999) highlighting the need to provide upstream, midstream and downstream interventions to achieve sustainable change.
Upstream
A key federal government priority is to develop a national policy for EDs in Australia, with a specific scheme for men, and should be informed by the NEDC 2012 National Framework. This policy should address which governing and clinical bodies are responsible for EDs and should address mechanisms for accountability within the states and territories. The aim of this policy would be to ensure EDs are a national priority and will assist in promoting a comprehensive, gender-specific and biopsychosocial understanding for men and women. This policy be supported by an increase of funding allocations or funding incentives for ED services and practitioners in Australia to provide specific support for men.
A federal government priority should be to develop and implement a media campaign with the aim of overcoming widespread stigma and educate the Australian community about men with EDs. The campaign should be informed by current empirical evidence and should promote positive body image and eating behaviours for men of all ages, contrary to negative cultural and media messages (Miller & Pumariega, 2001). This campaign should educate men on the risks of EDs and provide information for support services available. A section of this campaign should target frontline health professionals to ensure they are informed about this issue and respond appropriately.
Midstream
ED services and practitioners need to be able to access training to become educated about EDs in men. This training should include recommendations for providing appropriate support, therapy and treatment programs which met the specific biopsychosocial needs of men. ED services in Australia should be encouraged and supported to expand existing programs and interventions to be ‘male-friendly’ or implement new options with the aim of encouraging men to seek help (Dearden & Mulgrew, 2013). General health services should be provided with similar training and with specific screening tools to identify and support early intervention. NEDC (2010) argues early intervention is critical and evidenced to have positive outcomes; improving the burden on the healthcare system. It is further recommended integration and collaboration should be developed between physical and mental health services, ED services, public and private health services, professional disciplines and families of patients with EDs (NEDC, 2012).
Downstream
Regular medical treatment and psychological interventions are evidenced to be the best approach to manage and recover from EDs in Australia (NEDC, 2010). It is recommended men with EDs are able to access regular medical appointments for physical health, be able to access hospital inpatient or outpatient programs if required and a professional for long-term therapeutic support or a community support organisation for therapeutic interventions. Men should be encouraged to access the Mental Health Care Plan, Medicare benefits or bulk-billing to be able to afford and receive these essential services (DOH, 2015). Policies or initiatives which promote access for men from low socioeconomic communities to afford these services should be implemented.
Conclusion
It is evident the number of men with EDs in Australia is increasing (Bunnell, 2010). A social analysis of this issue and the current public health response demonstrates a female dominated approach towards EDs and services and interventions are failing to meet men’s needs (Drummond, 1999; Dearden & Mulgrew, 2013). Men are described as misunderstood, underdiagnosed and invisible in Australian society (Drummond, 1999; Strother et al., 2012). In order to improve this significant mental and physical health issue, Australia must implement a holistic and comprehensive public health response which addresses upstream, midstream and downstream interventions and builds upon the current NEDC 2012 National Framework.
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