Introduction

It is estimated that more than 30 million people in the United States suffer from some sort of eating disorder [1]. These include (but are not limited to) anorexia nervosa, bulimia nervosa, and binge eating disorder. There seems to be a common misconception that eating disorders only affect women. Although they disproportionately affect women, it is estimated that many men will also be affected by an eating disorder at some point in their life. Lifetime prevalence rates for men and women were 0.5% and 1.5%, respectively [1]. A more recent review of the eating disorder literature in men estimates lifetime prevalence rates of bulimia nervosa (specifically) between 0.13 and 1.34% [2]. It is important to note how difficult it is to get accurate statistics on how many people (in general) or men (specifically) have an eating disorder as many do not seek treatment because of the stigma surrounding the disorder.

Muise et al. [3] reviewed the adolescent and young adult literature on boys/men with eating disorders. Some of their general findings were that eating disorders had a strong developmental component and that there was a lag between onset and treatment. In reviewing the studies on bulimia nervosa specifically, they found that both boys and girls with bulimia nervosa also had other psychiatric comorbidities (like depression and substance abuse). Another study examined psychological comorbidity with men and women with eating disorders [4]. Of note, the highest rates of comorbidity existed for men with bulimia nervosa and for women with binge eating disorder. Both studies suggest that boys/men with bulimia nervosa are more likely to have other psychological problems above and beyond their eating disorder and the stigma surrounding those may exacerbate the treatment issue even further. Agüera et al. [5] examined men and women with eating disorders in cognitive behavioral therapy and found the highest dropout rates for men with bulimia nervosa (relative to other eating disorders and relative to women). Collectively, these studies suggest that men might be at a unique risk for bulimia nervosa, that their risk includes other comorbid conditions, and that they might not be getting the treatment they need to cope. This is part of the rationale for studying men with bulimia nervosa in the current study.

Mental illness, in general, is heavily stigmatized and this stigma is a major barrier for people with mental illness in seeking treatment. Roehrig and McClean [6] evaluated attitudes toward individuals with eating disorders (both anorexia nervosa and bulimia nervosa) compared to individuals with depression—with the rationale being they both represent stigmatizing mental disorders. Individuals with an eating disorder were rated as more responsible for their disorder, more fragile, and more likely to use their disorder to gain attention than individuals with depression. Moreover, they found that the majority of participants thought that there are some benefits to having an eating disorder (e.g., participants admired their ability to control eating), and that others would be motivated to imitate eating disorder behavior. Similarly, Mond and Arrighi [7] found that women with symptoms of eating disorders perceived disordered eating behaviors to be more acceptable (i.e., not that bad, nothing to be concerned about) compared to women without symptoms. This study demonstrated the nuance involved in the stigma surrounding eating disorders: disorders are not good but eating disorders are not perceived as entirely bad either. In examining only eating disorders, Wingfield et al. [8] looked at college student’s perceptions of people with anorexia nervosa and bulimia nervosa. They found that participants thought that individuals with bulimia nervosa were more responsible for their eating disorder and were more self-destructive than individuals with anorexia nervosa. In looking specifically at stigma towards bulimia nervosa, Rodgers et al. [9] found that while familiarity with bulimia nervosa was not related to stigmatizing attitudes, knowledge of bulimia nervosa was related to stigmatizing attitudes. Specifically, they found an indirect relationship between knowledge of bulimia nervosa and perceptions of personal responsibility suggesting the more you know about this particular disorder, the less you view someone with bulimia as personally responsible.

In an attempt to better understand and measure the stigma surrounding bulimia nervosa, McLean et al. [10] created a survey that defined five distinct components. This included advantages of bulimia nervosa, minimization/low seriousness, unreliability, social distance, and personal responsibility. They found that stigma was low on most subscales except for social distance and personal responsibility (where participants reported negative attitudes towards individuals with bulimia nervosa). Although both of the aforementioned studies [9, 10] tapped into this notion of responsibility, what is missing from both is an organizing framework with which to view stigma and thereby reduce stigma for public health campaigns.

The current study sought to fill this void using the attribution theory [11, 12]. Attribution theory [11] proposes a thought-feeling-behavior structure where a stigmatizing condition like bulimia nervosa triggers the search for a potential cause (e.g., who or what is responsible for the start of the condition; stigma onset). This triggers an emotional response that determines the behavioral response toward the individual with the stigmatizing condition. This theory also incorporates stability in predicting whether a perceiver will view a stigmatized person as being capable of change (stigma offset: can the condition be “cured” or managed through therapy, e.g.). Along those lines, Troop et al. [13] examined women prior to and after treatment for bulimia nervosa. Women who recovered from bulimia nervosa reported higher self-esteem after treatment. Of those, 38% attributed the responsibility of their improved status to themselves, 26% said it was because of other people or circumstances, and 36% said it was split equally between themselves and others. In terms of stigma offset, this study showed that women perceived that coping with the symptoms of bulimia nervosa was their own responsibility or others but that study did not define who those “other people or circumstances” were exactly. Other people could include family and friends or doctors and therapist or others with eating disorders and circumstances may also include things like media representations; however, other people and circumstances were not explicitly defined. In their review, Makowski et al. [14] found that both boys and girls were equally susceptible to parent and media influences which may be part of this nebulous “other people and circumstances.” Furthermore, Corrigan et al. [15] found that family members of those with mental illness can be blamed for both stigma onset and offset. In the case of a parent, especially the parent of a minor, this blame could have real implications for seeking treatment for their child’s mental illness—in this case, an eating disorder like bulimia nervosa.

In examining how others make those attributions, Makowski et al. [14] examined sex differences in attitudes towards women with eating disorders as they relate to social distance. Social distance is used as a construct in stigma research because we tend to want to stay away from people who are unappealing or stigmatizing. Makowski et al. found that women attributed anorexia nervosa to childhood sexual abuse and this was also related to greater social distance whereas men attributed bulimia nervosa to a brain disease and this was related to greater social distance. Both of the aforementioned studies examined women with eating disorders whether it is self-perception [13] or perceptions made by others [14], but perceptions of causal responsibility have yet to be examined for men with bulimia nervosa or their parents. Furthermore, none of the published literature has examined if or how perceptions of causal responsibility change over time.

Therefore, the goal of the current study was to investigate the stigma towards boys/men with bulimia nervosa across a developmental trajectory (from ages 12 to 24) to explore if/when stigma onset (causal responsibility) and stigma offset (coping responsibility) move between a parent and child. It was hypothesized that the child would be rated as less responsible for onset and offset when he was younger (e.g., age 12) than older (e.g., age 24). It was hypothesized that parents would be rated as more responsible for onset and offset when the child was younger than older. It was also hypothesized that mothers would be rated as more responsible relative to fathers [16, 17]. Furthermore, no formal hypotheses were made about differences in perceptions of controllability of symptoms, emotional responses, improvement, or behavioral responses but these were instead explored as research questions.

Method

Participants

Undergraduate students enrolled in an introductory psychology course (n = 370) were recruited through SONA participant pool to complete an online study for partial course credit. Ten participants were removed for incomplete or biased responses (e.g., leaving all of the items blank, answering all close-ended items with the same number, answering open-ended items with strings of letters/nonsense words) leaving a final sample of 360 (18% men, 81% women). Power analyses suggested this sample size would be adequate to detect moderate effects (α = 0.05, power = 0.80). Their ages ranged from 18 to 46 with a mean age of 18.7 (SD = 1.90). The sample showed some ethnic diversity: 38% White, 32% Latinx American, 18% Asian American/Pacific Islander, 9% bi/multiracial, and 3% African American. More than two-thirds of the sample (68%) reported being freshmen with smaller numbers of sophomores (25%), juniors (3%), and seniors (4%). The majority of the sample (99%) reported not being a parent (only 4 reported being a parent). The majority of the sample also reported not personally knowing anyone with an eating disorder. Specifically, with regards to knowing someone with an eating disorder, only 31% reported knowing someone with bulimia nervosa, 43% reported knowing someone with anorexia nervosa, 23% reported knowing someone with binge eating disorder. With regards to knowing the parents of someone with an eating disorder, fewer reported knowing the mother or father of someone with bulimia nervosa (11% and 8%, respectively), the mother or father of someone with anorexia nervosa (20% and 14%, respectively), or the mother or father of someone with binge eating disorder (6% and 6%, respectively).

Procedure

Participants logged into SONA, read the informed consent form, and informed consent was obtained from all individual participants included in the study. Participants were randomly assigned to one of five age conditions for Jared (the person in the vignette with bulimia nervosa): 12, 15, 18, 21, or 24. The participants began the study by reading a brief description of Jared. “Jared is a [age]-year-old male who has recently been diagnosed with bulimia nervosa. Bulimia nervosa is an eating disorder that involves binging (eating a lot of food in a short period of time) followed by purging (vomiting, using laxatives, fasting).” Upon reading the description of Jared, participants were then asked a series of questions about their perceptions, feelings, and behavioral tendencies toward Jared. Then, they were asked similar questions about Jared’s mother and Jared’s father. The survey took an average of 20 min to complete and participants were credited with SONA participation for their class. All materials and procedure were reviewed by the university IRB and verified as exempt (Protocol Number: HS-2018-0144, granted 05 September 2018). The data that support the findings of this study are available from the corresponding author upon request.

Materials

Most items map onto the attributional model and were modified [12, 18] to fit the current study. They were all rated on 9-point scales anchored at the extremes (1, not at all; 9, entirely). The primary variables of interest were two items assessing stigma onset and offset: “How responsible would you feel Jared is for causing his bulimia nervosa, that is for the start of this disorder?” and “How responsible would you feel Jared is for ending his bulimia nervosa, that is for curing or successfully coping with this disorder?” Two additional items were used to assess responsibility: “How much do you think Jared is to blame for his bulimia nervosa?” and “How much do you think it is Jared’s fault for experiencing these symptoms of bulimia nervosa?” And one additional item was used to assess coping: “How much do you feel that Jared is coping with his bulimia nervosa?” Three items were used to assess emotions (liking, pity, and anger) in the format, “How much [emotion] would you feel toward Jared?” One item was used to assess helping: “How much would you tend to help Jared?” Two items were used to assess perceived control of symptoms: “How much control do you feel Jared has over his bulimia nervosa symptoms, specifically the [binging/purging]?” Finally, one item was used to assess perceptions of general improvement: “How much would you feel that Jared’s bulimia nervosa would improve?” And three additional items were used to assess improvement as a result of treatment: “How much would you feel that [therapy/medication/a combination of therapy and medication] would be beneficial for Jared?” All items were modified for the perceptions, feelings, and behavioral tendencies toward Jared’s mother and father, separately with the exception of the improvement, benefits of medication, and benefits of a combination of therapy and medication items—since these were only asked about Jared.

Results

Preliminary analyses

Descriptive statistics (means and standard deviations) are presented for all variables of interest in Table 1 (for ratings of Jared), Table 2 (for ratings of Jared’s mother), and Table 3 (for ratings of Jared’s father) broken down by Jared’s age.

Table 1 Means (standard deviations) of all ratings of Jared, by Jared’s age
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Table 2 Means (standard deviations) of all ratings of Jared’s Mother, by Jared’s age
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Table 3 Means (standard deviations) of all ratings of Jared’s Father, by Jared’s age
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Hypotheses testing

A series of 5 (Jared’s age: 12, 15, 18, 21, 24) by 3 (ratings: Jared, Jared’s mother, Jared’s father) mixed-model multivariate analyses of covariances (MANCOVAs) were run for stigma onset (responsibility for onset, blame, and fault) and offset (responsibility offset and coping) with Jared’s age as a between-participants variable and ratings as a within-participants variable. Age, gender, ethnicity, and class level were included as covariates. There were no statistically significant differences between participants who knew someone with bulimia nervosa (or a parent of someone with bulimia nervosa) and those who did not so this was not included as a covariate. Covariate analyses are available from the corresponding author by request.

For stigma onset, MANCOVA showed an interaction between Jared’s age and ratings, Pillai’s Trace = 0.084, F(24,1812) = 2.18, p = 0.001, η2p  = 0.03. Univariate analyses showed that those effects were on responsibility onset, F(8,604) = 3.92, p < 0.001, η2p  = 0.05, and blame, F(8,604) = 3.05, p = 0.002, η2p  = 0.04. Simple effects tests indicated that ratings of Jared’s responsibility onset differed as a function of Jared’s age, F(4, 307) = 3.31, p = 0.011, partial η2 = 0.041. Specifically, the 12-year-old Jared was rated as much less responsible for the onset of bulimia nervosa (M = 3.03) compared to the 15-year-old Jared (M = 4.04, p = 0.031) or the 24-year-old Jared (M = 4.17, p = 0.011) which confirmed our hypotheses. Simple effects tests indicated that ratings of blame for Jared differed as a function of Jared’s age, F(4, 309) = 3.09, p = 0.016, partial η2 = 0.038. Specifically, the 12-year-old Jared was rated as much less to blame for his bulimia nervosa (M = 2.33) compared to the 24-year-old Jared (M = 3.54, p = 0.008) which confirmed our hypotheses. For stigma offset, MANCOVA showed no significant main effects (for Jared’s age or ratings) or interactions (all ps > 0.05).

Consistent with hypotheses, Jared’s mother was rated as more responsible for the onset of Jared’s bulimia nervosa (M = 3.48) compared to Jared’s father (M = 3.09), t(356) = 4.71, p < 0.001. Similarly, Jared’s mother (M = 5.08) was also rated as more responsible for the offset of Jared’s bulimia nervosa compared to Jared’s father (M = 4.58), t(356) = 5.73, p < 0.001. Jared’s mother was not rated higher than Jared’s father in terms of blame, fault, or coping (all ps > 0.05).

Research questions

Similar to the models run to test the formal hypotheses, a series of 5 (Jared’s age: 12, 15, 18, 21, 24) by 3 (ratings: Jared, Jared’s mother, Jared’s father) mixed-model MANCOVAs were run for emotional responses (liking, pity, and anger) and perceived control of symptoms (binging and purging) with Jared’s age as a between-participants variable and ratings as a within-participants variable. Age, gender, ethnicity, and class level were included as covariates.

For emotional responses, MANCOVA showed a significant main effect of ratings, Pillai’s Trace = 0.038, F(6,1214) = 3.93, p = 0.001, η2p  = 0.02. Univariate analyses showed that those effects were on liking, F(2,608) = 5.80, p = 0.003, η2p  = 0.02, and pity, F(2,608) = 4.46, p = 0.012, η2p  = 0.01. Pairwise comparisons using Bonferroni correction showed that Jared (M = 5.47) was liked more than his mother or father (Ms = 5.14 and 4.95, respectively; p = 0.002 and p < 0.001, respectively). Pairwise comparisons using Bonferroni correction showed that Jared (M = 5.82) was pitied more than his mother (M = 5.25, p < 0.001); and Jared and his mother were both pitied more than his father (M = 4.34, ps < 0.001). A significant between-subjects effect of Jared’s age was also found for liking, F(4,304) = 2.50, p = 0.043, η2p  = 0.03. Pairwise comparisons using Bonferroni correction showed that 12-year-old (M = 5.38) and 15-year-old Jared (M = 5.35) were liked more than the 24-year-old Jared (M = 4.72, ps = 0.089 and 0.087, respectively). For stigma offset, MANCOVA showed no significant main effects (for Jared’s age or ratings) or interactions (all ps > 0.05).

A series of 5 (Jared’s age: 12, 15, 18, 21, 24) by 3 (ratings: Jared, Jared’s mother, Jared’s father) mixed-model ANCOVAs were run for help and perceived benefits of therapy with Jared’s age as a between-participants variable and ratings as a within-participants variable. Age, gender, ethnicity, and class level were included as covariates. No main effects (of Jared’s age or ratings) or interactions were found for either variable (all ps > 0.05). Finally, for variables where ratings were made only for Jared (improvement, benefits of medication, and benefits of a combination of therapy and medication), Jared’s age differences were explored using ANCOVAs and none were found (all ps > 0.05).

Discussion

The goal of the current study was to examine the stigma surrounding boys/men with bulimia nervosa across a developmental trajectory (from ages 12 to 24) to explore if/when stigma onset (causal responsibility) and stigma offset (coping responsibility) move between a parent and child. As hypothesized, the younger Jared (12-year-old) was rated as much less responsible for the onset of and was less to blame for his bulimia nervosa compared to older 24-year-old Jared. However, there were no age-related differences in stigma offset for Jared nor were there differences in onset or offset for Jared’s parents—which was contrary to what was expected. Mukolo and Heflinger [19] found that attributions of parent blame were more likely with a mental illness than a physical illness. While they did not examine eating disorders specifically, they extrapolated that the nuance of disorder-specific stigma may trend in such a way that the more externalizing behaviors may elicit more parent blame. Arguably, a boy or man with bulimia nervosa binge eating and/or purging would be more externalizing than internalizing which may place the blame onto that boy or man and away from his parents. In looking at the values of stigma onset and blame, they were relatively low (well below the midpoint of the scale for Jared, Jared’s mother, and Jared’s father). Since our sample was low in familiarity with eating disorders (in general) and bulimia nervosa (specifically), it is not surprising that participants made relatively low ratings of stigma onset/blame to both Jared and his parents [9, 10]. In looking at values of stigma offset, they hovered around the midpoints of the scale for both the mother and father but climbed for Jared across the age groups (from 5.86 to 6.24) suggesting a slight push of coping responsibility for Jared age he aged but this did not reach significance. Since eating disorders are developmental in nature [3], the stigma surrounding eating disorders should also be approached with a developmental lens.

Age differences were found for stigma onset and blame; however, no age differences emerged for fault which suggests stigma is nuanced at least in the language we use to define it. “Responsibility for the cause of a disorder, that is for the start” and blame are different from fault and stigma reduction efforts in the context of both prevention and treatment efforts should be mindful of this. That no age differences were found for perceived controllability of symptoms suggests that the outsiders’ perception of control is consistent across adolescence and early adulthood [6]. In looking at the values of perceived controllability of symptoms, they were relatively low (well below the midpoint of the scale for Jared, Jared’s mother, and Jared’s father). Participants recognized that bulimia nervosa was not controllable by either Jared or his parents. Previous research [8] has found that while individuals with bulimia nervosa were rated as more responsible than individuals with anorexia nervosa, the values were still relatively low (midpoint of the scale) which is consistent with the current results. Although the current study did not compare bulimia nervosa with other eating disorders, these findings and previous research have important implications for prevention and treatment. Specifically, a “one-sized-fits-all” approach to stigma reduction in the treatment of eating disorders might not be effective and should be tailored to specific disorders.

With regards to parental differences, as hypothesized, Jared’s mother was rated as more to blame for Jared’s onset and offset of bulimia nervosa compared to Jared’s father. This is consistent with literature on the associative stigma that mothers (and not fathers) often face when their children have any sort of stigmatizing condition [16, 17]. However, more work should be explored in the area as gender plays an important role in the treatment of eating disorders in men [20]. If one or both parents are experiencing stigma related to their child’s illness, this may provide another barrier to seeking and receiving treatment for their child [15].

While the current study adds to the perception of stigma in a development context, it was not without limitations. The reliance on single-item, self-report measures to capture elements of the attribution model, although consistent with previous research [12, 18], has the potential for measurement error and response bias. The use of a brief vignette along with single-item measures was done with forethought and intention to (1) reduce participant burden and (2) to lend ecological validity to the stigma process. Oftentimes, we are given minimal information and time and therefore make snap decisions about liking or helping another person based on limited resources. However, future research should incorporate more information as well as behavioral measures to move beyond self-report of behavioral tendencies into actual behaviors. For example, including information about the parents in the vignette may result in subsequent changes in stigma [12]. Similarly, measuring social distancing in a ‘get to know you’ task with a boy/man with bulimia nervosa (or the parents of a boy/man with bulimia nervosa) would add to the stigma literature [10]. Another limitation was the reliance on a college student sample. Above and beyond convenience, this was also done with forethought and intention as this group in particular is more likely to suffer from eating disorders and/or to know someone who suffers from eating disorders. However, future studies should sample from adults who are not in college and with a wider age range to examine the external validity of these findings. Finally, using a non-clinical sample limits generalizability to clinical populations. An important next step would be to recruit boys/men with eating disorders as well as parents of boys/men with eating disorders.

Apart from these limitations, the current study adds to the stigma literature for boys/men with bulimia nervosa with a developmental context. Men’s risk for bulimia nervosa is unique in a number of ways: it often includes other comorbid mental illnesses (depression, substance use) [4], it may be exacerbated by longer delays between diagnoses and treatment [3], and men may not be getting the treatment needed to successfully cope [5, 20]. Stigma reduction could be immensely beneficial in terms of removing barriers for both boys/men with the disorder as well as for their parents, not only for seeking treatment but also for successfully completing treatment.