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Introduction

In the USA, it is estimated that ten million women and one million men meet the diagnostic criteria for an eating disorder. These numbers increase considerably when public health researchers or clinicians more broadly assess for eating-disordered behaviors. In fact, estimates of Eating Disorder Not Otherwise Specified range from 3 to 35 % of the US population. Though typically characterized as a disorder affecting White, middle-to-upper-middle class women, recent investigations increasingly demonstrate that eating disorders are prevalent across all demographic populations.

Despite these statistics, there is a paucity of research that investigates the epidemiology of eating disorders among men and even less is known of eating disorders among men of color. Though the current state of literature portrays eating disorders among men as clinically similar to eating disorders among women, there is evidence to suggest that race and gender are highly impactful in the etiology, course, and treatment of eating-disordered behaviors. After presenting a brief case study, this chapter will provide an overview of eating disorders, including a review of the following: types of eating disorders, prevalence and mortality rates, etiology, comorbidity, treatment recommendations, and outcomes. Following this, the chapter will focus on multicultural considerations of eating disorders, focusing on identities of race and gender. The chapter will review the effects of masculinity and racial identity on eating-disordered behaviors among men of color. After briefly summarizing the eating disorder literature that focuses on specific racial and ethnic groups, the chapter will conclude with recommendations for treatment, research, and clinical training.

Case Study

Stephen is a 21-year-old, Asian-American, heterosexual male attending a predominantly White collegiate institution in the Midwest. Stephen is a varsity athlete matriculating through the support of a wrestling scholarship. Stephen was referred to the student health center by his coach, following a fainting episode during Stephen’s most recent match.

In the course of routine medical assessment by the student health center’s physician, Stephen was asked if he had any concerns about his weight or body. Stephen replied affirmatively and reported patterns of eating-disordered behaviors that included bingeing, restriction, purging, and excessive exercise. Stephen attributed these behaviors to his training as a wrestler and reported engaging in these behaviors for approximately 2 years. During assessment, Stephen acknowledged that his eating behaviors were accompanied by negative physical effects, such as headaches, fatigue, gastrointestinal discomfort, and chest pain. With further probing, Stephen disclosed that he has also been struggling with negative mood states—including anxiety and depression—which frequently accompany his eating behaviors. Given these reports, Stephen was referred to the campus counseling center.

Upon intake by a staff clinician, Stephen elaborated on his eating behaviors and mood, as well as recent struggles in academics and social relationships. Stephen explained that his academic performance has steadily declined over the past two semesters, as characterized by frequent class absences, difficulty concentrating, and a lack of motivation to complete assignments. Stephen interprets this decline as a result of the demands of his athletic training and his difficulty in finding a balance between his performance as a wrestler and his performance as a student. Regarding social relationships, Stephen reports a difficult adjustment to campus life, beginning in his first year and persisting throughout his collegiate experience. Stephen explains that being a member of the wrestling team has made him feel more connected to the campus community; however, he reports having difficulty connecting to students on campus and notes increasing social withdrawal over the past year.

Though Stephen attributes his inadequate social support to the demands of wrestling, he also acknowledges that he feels out of place within the predominantly White campus community. Stephen described experiences of racial microaggressions, including fellow teammates or classmates ridiculing his stature and slim body shape and “model minority” references that mocked Stephen’s athleticism with reminders that he “should be studying math or science to keep up people like him.” When encouraged to speak about his concerns regarding his weight or body, Stephen explains that he feels “smaller” and “weaker” than his peers on the wrestling team. Moreover, despite his consistent successes each season, Stephen reports feeling as though he is “not really a good athlete” and does not “live up to the expectations” of others, including his coach and fellow teammates. After becoming more comfortable in the session, Stephen also reports feeling “physically unattractive” and “sexually undesirable.” Stephen attributes the absence of romantic relationships in his life to lacking “self-confidence” and “sexual prowess” as compared to teammates and other men on campus.

As Stephen’s counselor, how would you approach this case? How would you conceptualize his presenting concerns and plan for his treatment?

Overview

The preceding case study serves as an example of a clinical picture that receives scant attention in the mental health field: eating disorders among men of color. To date, the vast majority of empirical investigations and case studies of eating disorders diagnoses have focused on women—and more specifically on White, American, middle to upper-middle class, heterosexual women. As a result, eating-disordered behaviors have assumed a specific image, both within the minds of clinicians as well as the general population. However, researchers and clinicians have increasingly turned their attention to the prevalence of eating disorders within communities of color and amongst men. These efforts have illuminated how the diagnosis manifests among racial and ethnic minority women, gay and bisexual men, or among men of color.

This chapter will present an overview of eating disorders across the general US population and, more specifically, among men of color. To begin, the chapter will present the current context of the disorder by outlining the prevalence, etiology, treatment recommendations, and outcomes of eating disorders. Following this, the chapter will focus on how identities—gender, race, and ethnicity—interact with eating disorders and result in unique considerations of this diagnosis. Specifically, themes of masculinity, racial and ethnic identity development, acculturation, and sexuality will be examined so as to understand how each of these contributes to the overall clinical picture. Finally, recommendations for outreach, treatment, and future research will be made.

Eating Disorders

Broadly understood, eating disorders represent a spectrum of behaviors, thoughts, and emotions related to food, body image, weight, and exercise that manifest in a persistent pattern of dysfunctional eating or dieting behaviors. Scholars contend that eating-disordered behavior results from a combination of biological or genetic variables as well as environmental factors (Academy for Eating Disorders, 2012). According to the fourth edition of the Diagnostic and Statistical Manual, Text Revision, (DSM-IV-TR, 2000), eating-disordered behaviors take three forms: Anorexia Nervosa (307.1), Bulimia Nervosa (307.51), and Eating Disorder Not Otherwise Specified (307.50).

Anorexia nervosa (AN) (307.1) is characterized by the following symptoms: refusal to maintain body weight, intense fear of gaining weight, disturbance in the way in which one’s body weight or shape is experienced, and/or the absence of at least three consecutive menstrual cycles (DSM-IV-TR, 2000). AN is further classified into one of two types: restricting type and binge-eating/purging type. The restricting type represents a person who “has not regularly engaged in binge-eating or purging behavior”; the binge-eating type refers to a person who “has regularly engaged in binge-eating or purging behavior” (DSM-IV-TR, 2000, p. 583).

Bulimia Nervosa (BN) (307.51) is characterized by recurrent episodes of binge eating, in which an amount of food is consumed “that is larger than most people would eat during a similar period of time” and the person reports a “sense of lack of control over eating during the episode” (DSM-IV-TR, 2000, p. 583). Additional diagnostic criteria include “recurrent inappropriate compensatory behavior in order to prevent weight gain,” “self-evaluation is unduly influenced by body shape and weight,” and “the binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months” (p. 583). Similar to anorexia, bulimia is further specified by type: purging type and nonpurging type. Purging type entails the use of self-induced vomiting or the misuse of laxatives, diuretics, or enemas; the nonpurging type refers to a current bulimic episode in which the person uses other inappropriate compensatory behaviors, such as excessive exercise, to prevent weight gain.

Eating Disorder Not Otherwise Specified (EDNOS) (307.50) is a diagnostic category for disordered eating behaviors that do not meet the criteria for either AN or BN. EDNOS is commonly diagnosed when only some features of the aforementioned diagnoses are present. For example, in cases where the criteria for anorexia nervosa are met but the individual’s current weight is in the normal range, or in cases where binge eating or inappropriate compensatory mechanisms occur less frequently, the diagnosis of EDNOS may be applied. EDNOS is the most common eating disorder diagnosis.

Though not officially classified as an eating disorder in the current DSM-IV-TR, researchers—including the National Institute of Mental Health—and clinicians refer to a fourth category of eating disordered behaviors: Binge-Eating Disorder (BED) (National Institute of Mental Health, 2011). BED is characterized by recurrent binge-eating episodes in which a person experiences a loss of control over their consumption of food and an unusually large amount of food is consumed; however, unlike Bulimia, these episodes are not followed by inappropriate compensatory mechanisms. BED typically results in obesity and other negative health outcomes associated with obesity. The American Psychiatric Association reports that the DSM-V will include recognition of BED and distinguish BED from overeating due to the constellation of physical and psychological problems that accompany BED.

Finally, a disorder meriting inclusion in this discussion is Body Dysmorphic Disorder (BDD) (300.7); BDD is classified by the DSM-IV-TR as a somatoform disorder. Somatoform disorders, including Hypochondriasis and Somatization Disorder, constitute a category of disorders that are characterized by symptoms that typically result from a physical illness; however, these symptoms are not attributable to a medical condition, the effect of substance use, or another psychiatric condition. Rather, these symptoms are psychogenic and result from unconscious and ego-syntonic cognitions or emotions. BDD is described as a “preoccupation with an imagined defect in appearance…that causes clinically significant distress or impairment in social, occupational or other important areas of functioning” p. 583 (DSM-IV-TR). Thus, people with BDD typically report highly negative and inaccurate perceptions of their physicality, general appearance, or a specific feature of their body.

People with BDD tend to ruminate on the aforementioned perceptions; excessive preoccupation with their body results in emotional distress that typically results in depressive or anxious mood, compromised functioning of daily activities—including social withdrawal or isolation—and suicidal ideation or substance use. Diagnostically, BDD is distinct from Eating Disorders due to the lack of behavioral features (e.g., restriction or purging) as well as an absence of focus on weight or body shape. Nonetheless, as noted in subsequent sections, symptoms of BDD are commonly reported among people who believe they do not meet specific standards of beauty and athletes.

Prevalence and Mortality

Due to the range of eating-disordered behaviors, prevalence rates are imprecise. However, the National Institute of Mental Health, based on a National Comorbidity Survey Replication (Hudson, Hiripi, Pope, & Kessler, 2007), estimates that between five and ten million women and approximately one million men in the USA have an eating disorder diagnosis. According to the NIMH, at some time in their lives, 0.9 % of adult women and 0.3 % of adult men report anorexia, 1.5 % of adult women and 0.3 % of adult men report bulimia, and 3.5 % of women and 2 % of men report binge-eating disorder (Hudson et al., 2007). Though research consistently finds higher rates of ED among women, the first national study of eating disorders (n = 3,000 adults) found that 25 % of cases of AN and BN and 40 % of BED cases were male (Hudson et al., 2007).

Mental health professionals contend that these prevalence rates underestimate the pervasiveness of eating disordered behavior. Scholars and clinicians argue that two factors—under-reporting of symptomatology and inadequate physical and mental health services—obscure the frequency and severity of eating disorders (Hoek & van Hoeken, 2003; Levine & Smolak, 2006). Specifically, researchers note that under-reporting of symptomatology and lower rates of mental health help-seeking, particularly by men and racial and ethnic minority groups who do not fit the “classic” image of an eating disorder diagnosis, belie the scope of eating disorders (Mitchell & Mazzeo, 2004; Shaw, Ramierez, Trost, Randall, & Stice, 2004; Smolak & Striegel-Moore, 2001). Moreover, clinicians note that inadequate outreach, assessment, and treatment options for the aforementioned populations also result in underestimates of eating-disordered behavior. Thus, the prevalence of ED should be seen as higher than the aforementioned prevalence rates, particularly among men and racial and ethnic minority populations (Birmingham & Treasure, 2010; Walcott, Pratt, & Patel, 2003).

Despite these low prevalence rates relative to other psychiatric disorders, such as depression, AN has the highest mortality rate of any psychiatric disorder at 10 % (Birmingham & Treasure, 2010; Steinhausen, 2009). Though the national mortality rate of BN is lower than AN, at approximately 0.3 % (Keel & Mitchell, 1997), a recent study at the University of Minnesota Outpatient Eating Disorder Clinic (n = 1,885) found the mortality rate for BN was 3.9 % (Crow et al., 2009). Finally, though less is known of mortality rates for EDNOS, Crow et al. calculated the rate within their sample at 5.2 %. Given these alarming mortality rates, as well as the increasing prevalence of eating-disordered behaviors across all gender, racial, ethnic, and sexual orientation demographics, it is essential that researchers and clinicians better understand this growing epidemic.

Etiology

Scholars contend that a complex combination of biological and environmental factors are implicated in the development of an ED. Research indicates that eating disorders are significantly heritable and highly associated with alterations in neurological functioning; these biological features result in impairments of daily life functioning, including cognitive performance and emotional stability (Birmingham & Treasure, 2010; Klump, Bulik, Kaye, Treasure, & Tyson, 2009). Furthermore, some scholars contend that eating disorders are significantly associated with interpersonal and environmental variables, such as familial or cultural expectations of weight or body shape, media and social messages about physical appearance and beauty, and psychosocial stressors that result in depressive or anxious mood (Becker & Hamburg, 1996; Derenne & Baresin, 2006; Makino, Tsuboi, & Dennerstein, 2004; Miller & Pumariega, 2001; Pope, Phillips, & Olivarda, 2000).

As a result of this constellation of both organic and environmental factors, people with eating disorders use the control of food and their body as a means of coping with stressors or intense emotional responses to stressors. Through restriction, bingeing, purging, or excessive exercise, people with eating disorders develop maladaptive means of managing distress. Research demonstrates that eating-disordered behaviors become self-perpetuating, developing into patterns or rituals of behavior that are both physiologically and psychologically reinforcing. Eating-disordered behaviors result in significant cognitive, psychological, social, and physical effects. Cognitive effects include unusual preoccupation with food, weight, and body shape, self-critical attitudes about physical appearance, and ruminating thoughts about caloric intake and levels of physical activity. Psychological or emotional responses include feelings of guilt, depression, irritability, or anxiety associated with food, body size and exercise; moreover, changes in personality such as lower self-esteem and self-confidence, reduction in sexual interest, and changes in relationships also result from eating-disordered behaviors. Social responses include increased social isolation due to “secretive maintenance” of eating-disordered behaviors and a general decline in social functioning. Finally, physical responses to eating-disordered behaviors include impaired cognitive function, such as concentration, comprehension and judgment, visual and auditory disturbances, and amotivation. Additional physical responses include gastrointestinal distress, headaches, edema, hair loss, poor motor control, and compromised cardiac functioning (Academy for Eating Disorders, 2012; Birmingham & Treasure, 2010; Gardner & Garfinkel, 1997; National Institute of Mental Health, 2011).

Research consistently demonstrates a complex relationship between nutrition and physical health and psychological, cognitive, and social effects (Hudson et al., 2007; Keys, Brožek, Henschel, Mickelsen, & Taylor, 1950). Evidence points to direct and reciprocal influences of disordered eating behaviors and each of these psychosocial dimensions of functioning. Moreover, the reciprocity of these relationships refutes the common assumption that body weight is a matter of “will power”; instead, body weight and nutritional health are composed of a collection of behaviors, emotions, cognitive functioning, social-relational, genetic, and physiological factors (Gardner & Garfinkel, 1997; Tucker, 2006).

These factors vary by identity and reference-group membership. As a result, eating-disordered behavior must be understood within the context of social-cultural milieus. Factors contributing to an ED manifest differently based on gender, race, and ethnicity. Thus, clinicians must rely on culturally-competent assessment and treatment strategies, so as to effectively address the client’s needs. However, to date, there has been scant attention paid to the cultural variability of an eating disorder; there is a paucity of investigations or case study analysis that examines the constituent elements of eating disordered behavior amongst men or communities of color.

Comorbidity

Eating-disordered behaviors are frequently associated with other psychiatric disorders or features of mood and personality disturbances. For instance, depression and suicidality have been found to be highly correlated with all classifications of ED, including AN, BN, EDNOS, and BED (Franko & Keel, 2006; Levy, Dixon, & Sterns, 1989; Viesselman & Roig, 1985). Perfectionistic personality styles, expectations of high achievement, and poor self-esteem typically occur alongside all classifications of ED (Castro-Fornieles et al., 2007). Moreover, features of anxiety including Obsessive-Compulsive Disorder and Generalized Anxiety Disorder typically accompany diagnoses of AN (Kaye, Bulik, Thornton, Barbarich, & Masters, 2004; Thiel, Broocks, Ohlmeier, Jacoby, & Schussler, 1995). Research indicates that severe psychosocial stressors such as deaths or traumatic events are more likely to accompany BN; furthermore, substance abuse, impulsivity, self-injurious behavior, and sexual risk-taking are more likely with BN diagnoses (Levine & Smolak, 2006; Rosval et al., 2006).

Due to the great likelihood that eating-disordered behaviors present alongside other psychiatric symptomatology, it is essential that clinicians carefully and competently assess for eating disorders, particularly among populations that do not fit the classic clinical picture of ED. Moreover, given the alarming mortality rates of ED, it is essential that clinicians actively work to address eating-disordered behaviors as well as mood or personality features.

Treatment Recommendations

Research and clinical experience has determined that ED can be effectively treated through an interdisciplinary and multimodal regimen that includes psychoeducation, Cognitive-Behavioral Therapy, nutritional consultation, and medical monitoring (Gardner & Garfinkel, 1997; Murphy, Straebler, Cooper, & Fairburn, 2010; Whittal, Agras, & Gould, 1999). Psychopharmacology including antidepressant and antianxiety medications may also serve as an efficacious tool in the treatment of ED (Birmingham & Treasure, 2010; Carter et al., 2003).

Psychoeducation is an essential element of treatment that may occur within the context of a counseling relationship or between the client and a nutritionist or other medical professional. By educating the client, common myths about dieting and nutrition are debunked, while healthful habits are taught and encouraged. Specifically, clients are typically taught about the ineffectiveness of restricting, purging, laxatives, and diuretics in controlling weight, as well as the health risks of eating-disordered behavior and inappropriate compensatory strategies.

Cognitive-Behavioral Therapy (CBT) has been found to be a more efficacious modality of treatment due to its focus on symptom management through monitoring of thoughts, feelings, and behaviors. Clients with ED diagnoses are encouraged to observe and record triggers of eating-disordered behaviors such as dysphoric or anxious mood states, self-critical thoughts about weight or body shape, and psychosocial stressors in their environment. Following this, clients are tasked with identifying delay strategies and alternatives to ED behaviors or inappropriate compensatory strategies such as engaging with their social support, challenging negative self-talk with positive cognitions, or engaging in distracting or pleasurable activities.

Given the high rates of comorbid psychiatric diagnoses including anxiety and depression, CBT is frequently accompanied by medication management.

Consultation with nutritionists and medical professionals trained in ED is an invaluable means of supporting the work of mental health professionals. Consistent appointments with a nutritionist and medical monitoring reinforce the goals set in therapy and offer clinicians an interdisciplinary perspective on the welfare of the client. Moreover, given the aforementioned health consequences of AN, BN, EDNOS, and BED, it is essential that clients are assessed for physical consequences of eating-disordered behaviors.

Outcomes

Recent investigations of multidisciplinary efforts at ED treatment have produced encouraging results. In the care of AN, a combination of medical monitoring, nutritional rehabilitation, and psychological treatment—specifically cognitive-behavioral strategies that emphasize the relationship among thoughts, mood, and behavior—have proven effective (Attia & Walsh, 2009). Similar results were found in the evaluation of BN treatment; in addition to CBT, nutritional and medical monitoring and antidepressant medication were found to be highly effective (Bacaltchuk, Hay, & Trefilgio, 2001; Whittal et al., 1999). Lastly, investigations of BED found that psychotherapy (CBT), psychopharmacology, and weight loss efforts guided by a nutritionist or medical professional were efficacious treatment approaches (Carter et al., 2003; Wonderlich, Zwaan, Mitchell, Peterson, & Crow, 2003).

Despite these encouraging findings, the majority of efficacy studies have occurred within samples of white, heterosexual, middle to upper middle class females (Andersen, 1990; Becker, Franko, Speck, & Herzog, 2003; Cachelin, Rebeck, Veisel, & Striegel-Moore, 2001; Miller & Pumariega, 2001). There is a relative dearth of evidence supporting effective treatment recommendations for working with men or ED clients of color. The scarcity of empirical evidence for successful treatment strategies, as well as the under-utilization of mental health services, compromises the assessment and treatment of men and people of color struggling with eating-disordered behaviors.

Multicultural Considerations

Though the prevailing image of a client with ED takes the form of a White, American, middle to upper-middle class, heterosexual female, rates of eating disorders are increasing among men and communities of color. Some scholars contend that, among communities of color, rates of eating-disordered behaviors have remained generally constant over time, and the increase is due to greater clinical attention and outreach within these groups (Shaw et al., 2004; Smolak & Striegel-Moore, 2001; Walcott et al., 2003).

Other scholars contend that the increase in eating disorders among men and communities of color reflects changing cultural expectations of masculinity and the internalization of White standards of beauty. These scholars argue that men, previously unlikely to fit criteria for ED, are increasingly conscientious about body shape, weight, physical strength, and athleticism due to more demanding standards of beauty and higher expectations of appearance that have recently emerged in US society (Andersen, 1990; Drewnowski & Yee, 1987; Pope et al., 2000). Similar arguments contend that people of color, previously unlikely to fit criteria for ED, are increasingly struggling with achieving White standards of beauty that encourage the achievement of White body shapes, weight standards, and general physicality. The argument that the internalization of White, Western standards of beauty increases the likelihood of eating-disordered behavior is supported by global investigations of ED. International studies have found that, while eating-disordered behaviors abound in most industrialized societies, environmental factors—that include Western preferences for body shape, weight, size, and appearance—contribute significantly to the epidemiology of eating disorders (Makino et al., 2004; Markey, 2004; Nasser, 1988).

Scholars theorize that eating disorders are nested within three interconnected risk factors: personality, family, and culture. For instance, Streigel-Moore and Smolak (2000) offer support for the contributions of each of these factors to the development of eating-disordered behaviors and conclude that these factors inform the field’s current understanding of eating disorders. Scholarship also concludes that these interrelated factors—personality, family, and culture—are contingent upon developmental processes based on identities, such as race, ethnicity, or gender. Thus, there is broad consensus that cultural factors play a significant role in establishment and maintenance of beauty standards, as well as in the risk factors that frequently lead to eating-disordered behaviors (Becker & Hamburg, 1996; Bemporad, 1997; Walcott et al., 2003) Because one’s personality, family and culture is shaped by our reference group memberships—such as race, ethnicity, and gender—it is clear that both environmental and intrapscyhic factors can be best understood through a multiculturally competent framework of research and practice.

The following sections will explore how identity—specifically gender, race, and ethnicity—affect the genesis of eating disorders, specifically among men of color.

Gender and Masculinity

Gender can be understood as a spectrum of attitudes, values, beliefs, behaviors, and norms constructed to distinguish the male sex from the female sex. Gender (e.g., masculine, feminine) differs from the biological distinctions of male and female, in that gender refers broadly to social and cultural interpretations of how individuals enact or live according to their biologically assigned sex traits (Beal & Sternberg, 1993; Foucault, 1978; Hearn & Morgan, 1990). While there is some scholarly debate as to the extent that biology affects behavior, interests, preferences, and values, many scholars agree that gender and gender socialization processes exaggerate biological differences between the sexes and foster artificially constraining ways of being (Kimmel, 1996; Levant & Pollack, 1995; Perchuk & Posner, 1995).

Gender socialization is an ongoing and intensely salient process that commences at birth and results in the positioning of individuals within gender-appropriate gridlines. Where one falls along the gender map determines access to power, social acceptance, privilege, and psychological well-being. Although debate remains as to whether gender identity is solely constructed through socialization processes or is affected by biological determinants, it is clear that US society encourages internalized gender ideals that significantly shape developmental processes and the resulting gender identity (Berger & Luckmann, 1966; Gartner, 1999; Pollack, 1995, 1998). “Being a man is a crucial component of personal identity for males in [American] society, stemming from the early experience of gender as a self-defining characteristic” (Herek, 1993, p. 320).

Gender and gender socialization processes result in expressions of what it means to be male (masculinity) and what it means to be female (femininity). Masculinity has historically been associated with strength, independence, and dominance, as well as emotional restraint, violence, and athleticism; femininity has historically been associated with weakness, dependency, and indecision, as well as sensitivity, nurturance, and compassion (Fasteau, 1974; Foucault, 1978; Gilligan, 1982; Levant & Pollack, 1995). In addition to cultivating behaviors, interests, preferences, and values, gender socialization draws on images and appearances of masculinity or femininity that encourage visual distinctions between the sexes. Thus, masculinity is associated with specific phenotypes or body shapes that physically manifest the aforementioned personality or behavioral traits (Perchuk & Posner, 1995; Pope et al., 2000).

In Western culture, men are generally socialized to aspire toward a physical form so as to outwardly display their masculine characteristics; ideals of height, weight, and body shape constitute the masculine physical form so as to distinguish it from the female form and visually manifest their masculinity. The idealized masculine physical form also serves as a means of acquiring social privileges afforded to men and a means of exerting physical prowess over other men. Height is one physical feature that is operationalized by gender: the taller the man, the more masculine he is typically perceived to be. The ideal male height is not only greater than the average height of a woman but also greater than the average height of a man. For men, height tends to positively correlate with social perceptions of power, athleticism, confidence, strength, and, thus, masculinity. As a result, taller men are perceived to be more masculine, whereas shorter men—relative to other men and particularly relative to women—are perceived to be less masculine (Fasteau, 1974; Kimmel, 1996; Rotundo, 1993).

Western gender socialization also operationalizes the male body shape, including weight and musculature. Similar to ideals of height, masculine ideals of weight and musculature reflect inner characteristics of masculinity and manifest traits of strength, athleticism, power, confidence, and sexual prowess. Scholars contend that these ideals of weight and musculature have become increasingly demanding in Western society over the past decades (Drewnowski & Yee, 1987; Rotundo, 1993). Evidence suggests that male standards of body shape are following patterns of social and psychological influence that mimic female standards of beauty. The idealized masculine form, transmitted through multimedia platforms, represents a physical shape that is dominant, muscular, athletic, and sexually desirable (Kearney-Cooke & Steichen-Asch, 1990; Pope et al., 2000).

The evolution of this form can be traced through early depictions of male beauty to current examples of visual media, Hollywood icons, and even children’s male action figures. Over time, the weight and musculature of these idealized male forms have trended toward a mesomorphic physique—that is, lower levels of body fat and exaggerated development of muscle mass (Pope et al., 2000). Due to the emphasis on lean and muscular body shapes, masculinity is increasingly visually represented by action-hero celebrities, such as Sylvester Stallone or the embellished muscle development of steroid use, such as that of professional athletes (Dyer, 1997; Thompson & Cafri, 2007). Research demonstrates that the idealized masculine form has evolved toward a degree of unrealistic standards that frequently results in eating-disordered behaviors. Specifically, excessive exercise, binge eating, purging, and the misuse of compensatory mechanisms, such as laxatives or steroids may represent efforts at attaining the idealized male form (Andersen, Barlett, Morgan, & Brownell, 1995; Goldfield, Blouin, & Woodside, 2006; Hildebrandt, Alfano, & Langenbucher, 2010). These exaggerated and even impossible physical depictions of masculinity encourage and, at times, require cognitive preoccupation with weight and body shape, negative self-appraisal of features that do not fit these standards of masculinity, and the enactment of eating-disordered behaviors in an effort to achieve the idealized male form (Kearney-Cooke & Steichen-Asch, 1990).

Scholars argue that the increasing demands of the idealized masculine body form correlate to the increasing rates of eating disorders among the male population (Chung, 2001; Murray et al., 2012). Research demonstrates that, including among gay and bisexual samples of men, efforts to attain masculine standards of beauty result in eating-disordered behaviors—including excessive exercise and cycles of bingeing and purging (Carlat, Camargo, & Herzog, 1997; Herzog, Newman, Yeh, & Warshaw, 1991; Herzog, Norman, Gordon, & Pepose, 1984). These samples also report the psychological effects of eating disorders including ruminating and negative cognitions focused on weight or body shape, depressive or anxious mood, and social isolation. However, more research and clinical training is necessary to understand eating disorders among other subpopulations of men, including men of color.

Race and Racial Identity

Gender socialization and ideals of masculinity exist within a specific racial–cultural context. Interconnections between race and gender are reinforced through the racial and gender identity development processes and ultimately nested within the cultural milieus of these reference groups. Within the American masculine/feminine dichotomization process, gender norms are subtly informed by the values, norms, and behaviors of racial and ethnic identities. Thus, gender socialization and definitions of masculinity are significantly shaped by racial reference group memberships.

Researchers have found that it is the racial identity of an individual that is more predictive of their identity than the mere phenotypic quality of an individual’s race. In other words, the categorical designation “Asian,” “Black,” “White,” or “Latino” is less important than the internalized values, norms, and beliefs that are utilized to understand the racial self, the race of others, and the meaning these identities hold. A racial identity is constructed through the internalization of explicit and tacit messages that abound in the environment (Carter, 1995; Dyer, 1997; Helms, 1990; 1994). This internalization of racial messages fosters an understanding of oneself and others as racial beings. Scholars argue that the development of a racial identity varies within racial categories, creating significant within-group differences that are highly significant in understanding the impact of race on self-construal, interaction with the environment, and mental health (Carter & Jones, 1996; Helms, 1994; Thompson & Neville, 1999).

In summary, researchers argue that race is merely a phenotypic description that is far less psychologically impactful than racial identity—that is, the internalization and enactment of attitudes, behaviors, and values consistent with a racial reference group. Scholars argue that racial identities are constructed through a transmission of cultural mores by means of traditions, developmental experiences, and explicit or tacit messages about the meaning of phenotype, heritage, and position within a global society (Carter, 1995; Helms, 1990; Sue & Sue, 2003). According to development models, statuses of racial identity more directly account for psychological functioning and self-construal, including how one defines and internalizes masculinity, than the color of one’s skin.

Men of Color and Masculinity

Scholars argue that gender identity and gender roles are culturally defined; men internalize the masculine norms, values, and behaviors of their racial–ethnic reference groups (Brod, 1987; O’Neil, Good, & Holmes, 1995). Thus, masculinity may vary from one racial or ethnic group to another. However, in America, variability among minority racial groups exists within a larger social system that privileges white, Western norms of masculinity, thereby creating additional stressors or conflict. On the one hand, men of color may feel pulled toward comporting with white, Western ideals of masculinity so as to gain social acceptance and privileges; on the other hand, men of color may feel pulled toward embracing ideals of masculinity that are specific to their racial group membership, so as to cope with racism and ally with their marginalized racial group.

Racial identity and acculturation impact the internalization of masculine norms. Racial identity status or level of acculturation may account for the degree to which a man of color subscribes to white, Western standards of masculinity vis-à-vis their racial or ethnic group’s standards of masculinity. Nonetheless, scholars argue that unhealthy ideals of masculine body shape and weight exist in both white communities and communities of color. Summarizing a paucity of research and clinical literature, the following sections outline the phenomenon of eating disorders among men of color.

Men of Color and Eating Disorders

Rates of prevalence and mortality of eating disorders among Men of Color are generally absent from the broader eating disorder literature. Scholars point to several factors to account for this lack of knowledge. Significant under-reporting of eating-disordered behaviors among communities of color, inadequate outreach by mental health professionals, and high treatment attrition rates among men of color are frequently cited as explanatory reasons (Alegria et al., 2007; Franko, 2007; Nicdao, Hong, & Takeuchi, 2007; Taylor, Caldwell, Baser, Faison, & Jackson, 2007). These factors coexist alongside an adaptive mistrust of mental health professionals among communities of color, due to experiences of systemic, institutional, and individual racism that run throughout the history of medicine and the disciplines of psychiatry and psychology in particular. Similarly, the paucity of culturally competent and accessible mental health resources within communities of color may account for the under-representation of men of color in the eating disorder literature.

However, recent research suggests that eating disorders within communities of color occur at rates approximately consistent with White communities, and these rates are increasing among women and men of color. For instance, Striegel-Moore et al. (2003) found that black women were as likely as white women to report binge eating but more likely than their white peers to report restricting and use of compensatory mechanisms like laxatives or diuretics. Emerging research and clinical reports are reaching a broad consensus that rates of eating disorders within communities of color are relatively consistent with rates of eating disorders within the White population (Cachelin & Regan, 2009; Dohm, Brown, Cachelin, & Striegel-Moore, 2010). From this budding evidence, it should be assumed that men of color constitute approximately 10 % of people of color seeking treatment for eating-disordered behaviors are men.

Given emerging research findings of the general consistencies of eating disorders across racial and gender demographics, scholars contend that etiological factors of eating-disordered behaviors among men of color include both biological and environmental factors. Biological precipitants include those heritable and organic features that are associated with altered neurological functioning and result in impaired daily functioning. Environmental factors include those interpersonal, familial, or cultural expectations of weight and body shape, as well as media and social messages about physical appearance and beauty. For men of color, the internalization of white standards of male beauty, as well as the internalization of standards of beauty from their racial group, may contribute to eating disordered behaviors (Andersen, 1990; Taylor et al., 2007; Thompson & Cafri, 2007).

The comorbidity of other psychiatric disorders with eating disorders is also evident in the emerging research on men of color and eating disorders. As eating-disordered behaviors develop, symptoms of depression, anxiety, and suicidality also emerge. Men of color with eating disorders also report impaired functioning of daily activities including social withdrawal or isolation, as well as compromised cognitive functioning and general psychological distress. Moreover, due to the common myth that eating disorders afflict only white, middle or upper middle class women, men of color with eating disorders may feel additionally distressed and isolated. Due to the lack of clinical attention to and understanding of this disorder among men of color, this population may feel there are no resources for their needs or as though they are ignored by the mental health profession. Thus, comorbid mood disorders, social withdrawal, and suicidality may be exacerbated among men of color with eating disorders (Franko, 2007; National Institute of Mental Health, 2011; Thompson & Cafri, 2007).

Finally, recent scholarship indicates that the treatment of eating disorders among men of color is most effective when clinicians employ culturally competent, multidisciplinary methods. Specifically, research recommends the use of culturally appropriate psychoeducation materials that increase the client’s knowledge of eating-disordered behaviors and their understanding of general nutritional health within a culturally relevant framework (Maine, Davis, & Shure, 2009; Markey, 2004; Walcott et al., 2003). Specifically, researchers and clinicians recommend cognitive-behavioral strategies that incorporate culturally appropriate values, cognitions, or behaviors in an individual or group modality. Consultation with a nutritionist or medical professional who has experience treating eating-disordered behaviors among racial or ethnic minorities can be an effective adjunctive (Becker et al., 2003; Dohm et al., 2010). Medical monitoring or nutrition consultations can reinforce the psychoeducation and cognitive-behavioral strategies resulting from the client’s work with a mental health professional. Once again, it is essential that the nutritionist or medical professional establish rapport with the client and that strategies to improve nutritional habits are framed within a racially or ethnically syntonic framework. Finally, the use of psychopharmacology can be of benefit to those men of color with comorbid mood disorders or compromised functioning of daily activities such as cognitive deficits or social isolation (Birmingham & Treasure, 2010).

African-American or Black Men and Eating Disorders

Few empirical studies have investigated eating disorders among African-American men. In addition to the aforementioned factors that attempt to explain the lack of research and clinical attention to communities of color, research among African-American men suggests another factor: age of onset. As reported by Lawlor, Burket, and Hodgin (1987) in an early investigation of eating-disordered behaviors among African-American men, the emergence of eating-disordered behaviors ranges from their late teens to their early thirties, suggesting a delayed onset of eating disorders among African-American men relative to other populations (Lawlor et al., 1987). Thus, age may constitute a significant variable among African-American men that both contributes to the development of an eating disorder as well as obscuring the prevalence of eating disorders within this population.

A study by Robinson and Anderson (1985) constitutes one of the earliest investigations of eating disorders within the African-American population; the authors employed a case study methodology to examine anorexia nervosa among three African-American women and two African-American men. Detailing the clinical course of the client’s eating disorders, the authors emphasized the need for greater research and clinical attention to be directed toward eating disorders among African Americans and challenged the dominant, clinical picture of eating disorders as a white, middle-class female phenomenon.

Subsequent research among African-American adolescents and men has found that African-American men and boys are generally more satisfied with their weight and body type (Story, French, Resnick, & Blum, 1995; Wimbish, 2009). Story et al. (1995) found that African-American adolescent boys were more satisfied with their weight and body than their adolescent White peers. Similarly, Wimbish (2009) found that, regardless of sexual orientation, African-American adult men were generally satisfied with their weight and body shape. However, both the heterosexual and gay/bisexual subsamples viewed muscularity as an important element in the construction of a racial identity and reported similar concerns about how their body shape conforms to culturally-informed definitions of masculinity. Thus, while the African-American men in the study were generally satisfied with their body, they were conscious of how their body shape or size fit within African-American ideals of masculinity.

An investigation by Wimbish (2006) found that adult African-American men who highly value physical attractiveness are more likely to report greater dissatisfaction with their body size or appearance. Wimbish concluded that gay and bisexual African-American men who were dissatisfied with their body tended to attribute that dissatisfaction to a desire to appear more masculine rather than a desire to be thin. Thus, while African-American adolescents and men may report more positive attitudes toward their bodies than their White peers, there is some evidence that negative self-appraisals and eating-disordered behaviors may be driven predominantly by ideals of the masculine African-American form.

Finally, data from the National Survey of American Life (2007) offer rare analysis of lifetime and 12-month prevalence rates of eating-disordered behaviors among Black and African-American men. Taylor et al. (2007) reviewed the responses of 5,191 Black and African-American adults, 44 % of whom were men; ethnic subgroups included African American (n = 3,570) and Caribbean Blacks (n = 1,621). For male respondents, lifetime prevalence rates of eating-disordered behaviors were 0.20 % (AN), 0.97 % (BN), and 4.14 % (Any binge eating). Consistent with the broader ED literature, the authors found that adult women generally reported higher lifetime and 12-month prevalence rates of eating-disordered behaviors. However, the authors found no gender difference in eating-disordered behaviors among adolescents. The authors note that these rates “point to a tendency for boys to exhibit eating-disordered behaviors during adolescence” and hypothesize that this phenomenon may be attributed to participation in sports. Nonetheless, the authors emphasize: “our findings provide evidence that Black boys may not be immune to eating disorders” (Taylor et al., 2007, p. S13).

Asian-American Men and Eating Disorders

Though relatively few, investigations of eating disorders among Asian-American men offer preliminary results and highlight the need for additional research to inform clinicians’ approach to working with this population and inform future scholarship. For instance, in a study of bulimia in adolescents, Gross and Rosen (1988) found that Asian adolescents had similar rates of eating disorder behaviors when compared to White male respondents. Furthermore, Mintz and Kashubeck (1999) found no differences between self reports of eating-disordered behaviors among Asian-American men and White American men, concluding that, for men, race does not significantly affect eating-disordered behavior. From Gross and Rosen (1988) and Mintz and Kashubeck’s (1999) research, one may conclude that eating disorders occur as frequently among Asian-American men as their White American male peers.

In an effort to raise clinical awareness and further explore the nuances of racial/ethnic identity group membership and eating disorders, Nicdao et al. (2007) analyzed data from the National Latino and Asian American Study (n = 2,095). The authors report that, though prevalence rates are relatively low, eating disorders are present among Asian-American men; lifetime prevalence rates for AN, BN, BED, or “Any binge eating” were 0.05 %, 0.71 %, 1.35 %, and 3.94 %, respectively. The authors found that among this Asian cohort, and consistent with the broader ED literature, women exhibited more disordered eating behaviors relative to men; however, Asian-American men did report eating-disordered behaviors at rates that were approximately consistent with reports of ED behaviors among men in the general population (Hudson et al., 2007). Thus, while there is a paucity of research that focuses on Asian-American men and eating disorders, there is evidence that eating-disordered behaviors approximate those of the White male population; nonetheless, the factors that contribute to these behaviors would be best understood through culturally competent research and clinical practice.

Hispanic or Latino Men and Eating Disorders

Like other men of color, Hispanic or Latino men are also generally absent from eating disorder literature. However, emerging research indicates that eating-disordered behaviors among Hispanic or Latino men constitute a significant health risk within this community. For instance, Alegria et al. (2007) presented the first investigation of lifetime and 12-month prevalence estimates of a nationally representative sample of the US Latino population. The authors analyzed data from the National Latino and Asian-American Study (n = 2,554), collected between May 2002 and December 2003. Four major ethnic subgroups participated: Cubans (n = 577), Mexicans (n = 868), Puerto Ricans (n = 495), and “Other Latinos” (n = 614).

In this groundbreaking study, the researchers found that Latina women reported higher lifetime and 12-month prevalence rates than Latino men for bulimia nervosa, binge-eating disorder, and “any binge eating”; however, gender differences were not statistically significant. For Latino men, lifetime prevalence rates were 0.03 % (AN), 1.34 % (BN), 1.55 % (BED), and 5.43 % (Any binge eating). These rates were relatively consistent with yet slightly higher than lifetime prevalence rates of Asian-American men and slightly lower than lifetime prevalence rates of African-American or Black men, as previously reported.

Alegria et al. (2007) conclude that binge-eating behaviors are more prevalent than restricting behaviors among Latinos. Moreover, the authors concluded that Latinos born outside of the USA were less likely to report binge-eating behaviors, while Latinos who have lived more than 70 % of their lifetime in the USA were more likely to report restrictive behaviors, such as BN. “Preoccupation with slimness might be increasingly adopted as Latinos integrate U.S. conceptions of beauty, losing their defense against eating disorders” (Alegria, 2007, p. S19). Results of this rare investigation of Latino men and eating disordered behaviors echo of the prevalence rates among other communities of color and highlight the necessity for further research and clinical attention to this mental health trend.

Native American Men and Eating Disorders

Among Native Americans, rates of obesity and comorbid health disorders such as diabetes and hypertension are disproportionate relative to other racial and ethnic groups. Research indicates that adult American Indian/Alaskan Natives are 1.6 times more likely to be obese than Non-Hispanic White adults (CDC, 2012). Moreover, 34 % of Native American males and 40 % of Native American females self-reported as overweight, as compared to 24 % of the general US male population and 25 % of the general US female population (U.S. Department of Health and Human Services, 2010). As a result of these public health statistics, empirical studies of nutritional health within this population have overwhelmingly attended to binge-eating disorder (BED). Of the paucity of eating disorder investigations among Native Americans, or American Indians/Alaskan Native, research has focused on binge eating-disordered behaviors and obesity, so as to better understand the variables contributing to these significant disparities in health outcomes (Striegel-Moore et al., 2011).

Scholars contend that multiple factors account for the rates of obesity and comorbid health disorders among Native American men. Specifically, researchers argue that the collective effects of heritable and behavioral variables—such as genetics and dietary practices—as well as psychosocial stressors—such as poverty, racism and acculturation stress—contribute to BED and poor health outcomes among Native Americans, or American Indians/Alaskan Native men. Biobehavioral health studies suggest that variables of genetics and dietary practices partially explain the health outcomes of Native American men. While these variables affect weight and overall health for all populations, research suggests that Native Americans may be more susceptible to obesity due to the effects of a Western diet—that is, a diet which is higher in saturated fats, sugars, and processed ingredients (Jollie-Trottier, Holm, & McDonald, 2009; Ravussin, Valencia, Esparza, Bennett, & Schulz, 1994). Analogous to the ill effects of alcohol, rates of obesity, diabetes, and hypertension may be higher among Native American men due to a genetic predisposition that favors a native diet and dietary practices. Given the accessibility, abundance, and dominance of a Western diet, Native American men may be more likely to become overweight and suffer from health disorders associated with obesity (Schulz et al., 2006; Story et al., 1999).

Psychosocial stressors may also account for binge eating-disordered behaviors. Scholars suggest that Native American men may rely on food as a mechanism of coping with poverty, racism, and acculturation stress. A diet of high-fat foods, coupled with sedentary lifestyles, contributes to obesity among impoverished populations including Native Americans. Among Native American men, poverty may exert a nutritional double-bind: food is a coping mechanism for the stress of poverty, and poverty conditions disallow for healthful dietary options. Similarly, the literature identifies a link between the effects of racism and acculturation stress on physical health—as Native American men cope with acculturation or systemic, institutional, and individual racism, they may turn to food. Binge-eating behaviors may be used as a mechanism for self-soothing, and the food consumed is likely to be low cost but high in fat. Thus poverty, racism, and acculturation stress are likely to contribute to disproportionate rates of eating-disordered behaviors, obesity, diabetes, and hypertension among Native American populations.

Conclusion

In sum, eating disorders have the highest mortality rate of any psychiatric disorder, and the prevalence of eating disordered behavior is increasing among men, including men of color. Though there is a dearth of scholarship that investigates the epidemiology of eating disorders among racial or ethnic minority men, it is clear that rates of disordered eating behaviors approximate those of the general male population. Moreover, the factors that contribute to eating-disordered behaviors—including heritable, personality, familial, and social variables—are nested within identities of race and ethnicity. These racial or ethnic identities result in developmental processes that inform standards of masculinity, the masculine form, and culturally informed expectations of weight, body shape or size, and physical appearance.

More research is necessary to better understand the phenomenon of eating disorders, eating-disordered behaviors, and the factors that contribute to both among racial and ethnic minority, male populations. Specifically, scholars must evaluate the contributions of racial and ethnic identity, acculturation, and gender socialization to variables of body image, self-esteem, standards of beauty, and self-appraisals of body shape, weight, or physical appearance. Research must investigate the confluence of racial, ethnic, and gender differences among and between men so as to better understand the factors that contribute to or buffer against eating-disordered behaviors.

Clinical training must acknowledge the prevalence of eating-disordered behaviors among men of color and challenge the dominant image of eating disorders as exclusive to White, middle to upper-middle class women. Mental health professionals should ally with other medical professionals including nutritionists and physicians, to increase outreach, screening, treatment, and community-based interventions among men of color. Assessment of eating-disordered behaviors or the factors that contribute to eating disorders—such as preoccupation with body shape or concerns about nutrition—should be standard protocol of clinical intake procedures. Screening for eating disorders should be standardized among hospital, counseling center, and community clinic staff, so as to afford all patients who seek care the opportunity to discuss concerns about their weight or nutritional health. Finally, clinicians should contribute to the paucity of research through clinical case study and treatment recommendations, based on their work with men of color.

Ultimately, the treatment of eating disorders like all mental health disorders must be culturally competent. Reaching this goal requires multidisciplinary efforts among researchers and clinicians alike; these efforts must acknowledge the impact of masculinity, acculturation, and racial–ethnic identity in the development and effective treatment of eating disorders.