Fat: a male issue too

After rummaging through papers on eating disorders and disentangling himself from the all-purpose medical model, this is one man's personal quest to understand the individual male client's perspective. By Duncan E Stafford

I studied with three different organisations during my six years' training to become a psychodynamic counsellor. Overall, I had 52 peers, of whom 50 were female. While the course providers commented that the gender imbalance was 'a pity', none seemed able to address the issue practically.

This uneven mix allowed less opportunity to explore gender dynamics during core course discussions and experiential work. However, a positive outcome from this situation, for me, was that when men were also the minority gender in writings, I questioned the validity and relevance of this position.

In my clinical work, I became increasingly interested in people with eating disorders and made several forays into the literature of the subject. Understandably, then, my attention was caught by Morton¹, Whytt² and Willan³ when I discovered they had written the first three reported cases of anorexia nervosa and that these were all of men.

Towards the end of my training, during some postgraduate study, I had both the reason and opportunity to begin a detailed literature review of anorexia nervosa (AN) and bulimia nervosa (BN), and I focused specifically on looking for case studies of males with the disorders.

A steady trawl through papers on eating disorders largely confirmed a 'medical model' approach. They described the conditions not in terms of distressed people, but rather as a population of patients with a common set of symptoms. There was a repeated message in these writings about wanting to see larger sample sizes of males with AN and BN to help with statistical analysis, and a call for healthcare professionals to consider BN or AN in males as a diagnosis.

As you might imagine, medical-model papers on the whole express very little, if anything, of the human suffering counsellors and psychotherapists are entrusted with when working with AN and BN sufferers in their consulting rooms. I became aware that the fact that fewer men manifest AN and BN (the collective view of the papers I read) was of little consequence when viewing another person's story in a therapeutic relationship.

The search for the story of the individual is perhaps a search that cannot easily be reported in empirical, medical and academic reports and yet it seems that the medical model has, for far too long, been predominant in informing much of our own baseline thinking when working with people.

Among the papers and texts I read, I found four key pieces that informed me about the individual story I was searching for: Michael Krasnow's autobiography, My life as a Male Anorexic⁴; Ralph Wilps' paper, Male Bulimia Nervosa: An Autobiographical Case Study⁵; Thomas Holbrook's autobiographical paper, Walking in the Woods⁶; and J Dunkeld Turnbull et al's study, Physical and Psychological Characteristics of Five Male Bulimics⁷. Having collected and 'ingested' a vast number of papers on this subject my next challenge became a personal one.

A love of food

As a man in early middle age, I have rarely given diet or weight much consideration, other than to become vegetarian in my mid-20s. While many of the associated descriptive features and disorders of this field of work – such as anxiety, depressive symptoms or issues with control – were in my working canon as a counsellor, eating itself had never been anything other than a pleasurable activity for me. To eat is to be involved in a sensory activity; the texture, temperature, acidity or sweetness were all daily pleasures which extended to the enjoyment of food preparation for my family and friends. I had never dieted, nor thought about it for myself. Therefore, initially during my study, I found it a puzzling challenge that people could have such conflicted relationships with something that at its most basic is a necessity of life and at its grandest is a sensory and aesthetic delight. The more I engaged with the literature of males with eating disorders, the more difficult I found it to understand the central food component of the disorder.

In the pages of Krasnow's⁴ autobiography are descriptions of many of the usual symptoms of AN: food preoccupation and rituals; refusal to maintain body weight at appropriate levels for age, height and body type; intense fear of 'fat'; lying about the amount of food consumed; having difficulty eating with others around; depression; isolation; loneliness; unrealistic and perfectionist standards; compulsive behaviour; low self-esteem; and a need to control.

Reading about, and looking at, the pictures of a young man who eventually died of AN raised important questions. I asked myself: 'How would I work effectively with a male with AN or BN? What would be my empathic response?' Certainly, none of my studies had prepared me for such an encounter with a male. I felt the need to challenge my unconscious and cultural assumptions about men with eating disorders.

The quest for meaning

My method of 'challenge' was essentially practical. With the support of a supervisor and my own twice-a-week therapy, as well as my wife, I began by keeping a food inventory for a period of 29 days. Every morsel of food was weighed and every sip of liquid entered in a food diary in my attempt to 'buy into' some understanding of the compulsive nature of thinking about food at every contact. In addition, I kept notes about my feelings towards the 'experiment' and food. Empathetically, this became an interesting process, and I quickly found myself both understanding more about the obsessional quality of focusing on food and being aware of food cravings that I was unused to. The extra Mars bar bought and eaten on a visit to the newsagent became noticeable (and had to be recorded). The ability to view the day's or week's food intake induced a certain amount of guilt: I consider myself to eat a healthy vegetarian diet, but the reality is that a lot of junk food had crept in – indeed, an evening spent at home enjoying my best friend's company looked more like a bulimic binge when written down.

From day 15 of the diary, I continued the same notes on food and drink, but added the calorie count for everything I consumed. I found the effort enormous and relatively time consuming. On day 19, I wrote:

I find the effort of calorie counting mindless! Read a magazine article today about Matt Lynch, a recovered anorexic who used pencil dots on his thumb nail to monitor his calorie intake. Each mouthful equalled one dot. Once his thumb nail was full each day, he stopped eating. With some humour I write, I only wished I had thought of this! (Personal food diary).

The purpose of the calorie counting during the final eight days of my food diary experiment was to gain some limited effect of both AN and BN. I took a mean average of the calories I had eaten from days 15–21 (2,000 calories a day, approximately), and intended during the 'anorexic days' to restrict my diet to 1,000 calories and during the 'bulimic days' to attempt to double my calorific intake. In practice, I found it impossible to remove 1,000 calories a day from my diet, but I made 'better progress' towards doubling my calorific intake. On day 25, I ate almost 1,900 extra calories during a 'games evening' with a male friend. On the evening of day 27, I managed to consume almost 2,000 calories made up of chocolate, sugary products and cereals while reading descriptions of bulimic binges, including the chapter by Wilps.

Of course, my AN days might simply be viewed as a calorie-controlled diet. Understandably, during the 'BN-type days', I did not engage in any form of purging behaviour; however, the feelings of bloating would certainly have led me to a Roman vomitarium had one been available. 'Experimenting' with my food intake was a serious business, which I feel I had adequate support to undertake. Perhaps it seems quite an extreme venture – although, to me, looking back on it, the Morgan Spurlock film Supersize me⁸, released about a year after my month-long experiment, legitimised my method of enquiry. What my food diary experiment has given me is some real 'empathic knowledge' that I could use when working with AN/BN sufferers of both genders.

I can now 'hold', in the therapeutic hour, some of the unverbalisable discipline that is needed to maintain an anorexic position. I also have a limited insight into the physical discomforts, and at some moments in 'my month with food' I approached the aloneness that eating disorders can bring.

The personal voice

The other writings I mentioned (Holbrook, Wilps and Dunkeld Turnball et al) did not lead me to direct action as a human being or a professional. What they posed, in various ways, was a need to see the individual within an understanding of males with eating disorders. The Dunkeld Turnball paper reports more than 'facts', for example estimates of bulimic males in the UK population being extremely small compared to females. It informs its reader not just that 'Case 2' was a 28-year-old male who binged several times a week, but that he was a real person – a 28-year-old father of two children who was suffering chronic kidney failure, was bingeing on foods outside of his therapeutic diet, who had been an obese teenager placed on a 'meat only' diet by his obese mother; that he liked to eat the kinds of foods he binged on in the street straight after purchase, and when he was angry at his children, he never hit them, he threw food at them.

The medical-model writers and researchers who have 'called' for more males with eating disorders to be 'found' seem to have achieved very little within their framework over the last 18 years. Indeed, I feel that it is now up to those who write from, or include, the personal voice of the male sufferer of AN and BN to influence the research models. Through writings like Krasnow, Holbrook, Wilps and Dunkeld Turnball et al we learn more than the essential empirical detail that might inform those who work with men about the generalities, specificities and commonalities of the condition. More importantly for those who work educationally and therapeutically with males, we learn the specifics of the individual story. In being informed of the singular human story we potentially cease to blinker our views of the behaviours and gender bias that constitute being anorexic or bulimic – with the result that it is possible that a global change could be facilitated through a dissemination of such information.

If this were to happen, males with AN and BN might be able to ask for help more readily, males might more likely be considered by professionals as possible sufferers of these disorders. Recognising the individual in the literature of AN and BN has the potential to bring about change. Published writings from the individual voice in academic and popular media could lead to raised awareness of the condition in males and potentially to a transforming of the vicious circle of the literature I reviewed in 2003 into a virtuous circle in which males with AN and BN can emerge from beneath the shadows of a 'woman's disease'.

Was my relationship with food changed by my experiment? Yes, fundamentally and in a positive manner. I have hinted at the way in which I feel it has improved my therapeutic practice. But I now think and look at food as more than a pleasurable fuel for human consumption. I look at the wider debates about society, culture, class, gender and nutrition from a more informed position. Indeed, nutrition has become a central enquiry to 'wellbeing' and I am currently following a short science course with the Open University: 'Studying Human Nutrition'.

Duncan E. Stafford is a freelance counsellor, mentor, educator and facilitator. He is keen to network with other practitioners on male gender issues and discrimination, and males' current place in society. Contact him at: individuation@dsl.pipex.com 

References

1. Cited in Silverman JA. Anorexia nervosa in the male: early historic cases. In: Males with eating disorders. New York: Brunner-Routledge; 1990.
2. Cited in Silverman JA. Robert Whytt, 1714–1766, eighteenth-century limner of anorexia nervosa and bulimia: an essay. International Journal of Eating Disorders. 1987; 6(1):431–433.
3. Cited in Silverman JA. An eighteenth-century account of self-starvation in a male. International Journal of Eating Disorders. 1987; 6(3):144–146.
4. Krasnow M. My life as a male anorexic. New York: Harrington Park Press; 1996.
5. Wilps RF. Male bulimia nervosa: an autobiographical case study. In: Males with eating disorders. New York: Brunner-Routledge; 1990.
6. Holbrook T. Walking in the woods. In: Anderson A, Cohn L, Holbrook T. Making weight. Carlsbald, CA: Gruze Books; 2000.
7. Dunkeld Turnbull J, Freeman CPL, Barry F, Annandale A. Physical and psychological characteristics of five male bulimics. British Journal of Psychiatry. 1987; 150:25–29.
8. Spurlock M. Supersize me. Tartan Video; 2004.