PHILADELPHIA -- William Hornby looks straight into the camera, smiles and says:
“Hi, I’m William and I am a man who is proudly in eating disorder recovery.”
It’s the kind of public and unashamed acknowledgement the now 22-year old Temple University student wished he could have leaned on when he began his recovery in early 2020. The video has been watched more than 21,000 times since Hornby posted it on TikTok in December 2020.
An estimated 10 million men and boys have a diagnosed eating disorder - about a third of all reported cases, according to the National Eating Disorder Association. Yet because the condition is largely seen as a women’s health problem, men often struggle to find help.
Treatment centers primarily cater to women. Clinicians are trained to recognize eating disorders among women, but often don’t pick up on the different warning signs among men. Even self-help is hard to come by, with far fewer men than women speaking out publicly about their experience.
As a result, men are on average sicker when they’re finally diagnosed and more likely to require hospitalization, which makes their path to recovery that much harder.
“Often we don’t recognize they’re struggling until it’s too late,” said Brian Pollack, the founder and clinical director of Hilltop Behavioral Health in Summit, N.J. “They fall harder and quicker — or at least it’s perceived that way, because no one knows the signs and symptoms.”
There are good reasons resources are dedicated to treating eating disorders among women. The cultural ideals for many American women - tall, thin, beautiful - have contributed to generations of eating disorders, especially anorexia, among women and girls who felt immense pressure to resemble the Barbie dolls they played with and models they saw in magazines.
Clothing designers are increasingly including models of all sizes in their advertisements, children’s movies feature heroines who don’t wear crowns and corsets, and dolls with realistic body proportions line toy store shelves. But there’s still a long way to go to undo such ingrained ideas about body image.
At the same time, clinicians are grappling with how to better support men and boys experiencing body-image problems.
For men, movies and music that conflate masculinity with ripped physiques or lean, toned bodies can contribute to eating disorders. Gym culture – working out hard, eating nothing but lean protein then celebrating with indulgent “cheat day” meals – encourages a pattern of food restriction and binge eating.
“Behaviors might look the same [in men and women] but cognitive drivers are different and that’s linked to different body ideals,” said Stuart Murray, the director of the University of Southern California’s eating disorders program and a founder of the National Eating Disorders Association.
Men also perceive their eating behavior differently, which requires medical professionals to take a different approach to talking to men about these issues. For instance binge eating is considered a loss of control, however men who are taught to always be in control may not view their binge-restrict eating patterns that way, Murray said.
Growing up outside Baltimore, Hornby said being around family members who dieted routinely, thumbing through health magazines and having to change for gym class in a locker room full of his peers made him question how he looked. He started to restrict what and how much he ate.
“I would look at men’s health magazines and resent that I didn’t look like that and be scared that I never would,” Hornby recalled of his 11-year-old self.
Once on his own, in college, Hornby started to eat more, but would immediately feel guilty and force himself to limit his intake. At a particularly low point, he reached out to a Temple dietitian, who connected him to a therapist. With help from both of them, Hornby began to make progress in breaking his cycle in 2020.
But figuring out how to move forward from his pattern of restrictive eating and bingeing was hard because he felt alone.
“One of the most isolating and challenging things for me was I couldn’t find representation for men with eating disorders,” he said. “Even though I knew it was happening, I couldn’t find them.”
Because eating disorders have been cast as a female problem, men may not recognize that their relationship with food is also troubled. Those who do realize they have a problem may not know where to turn for help.
With an overwhelmingly female clientele, treatment centers often have a feminine aesthetic and programmatic approach to discussing eating disorders that doesn’t resonate with men, Pollack said.
“Whether it’s an all-female organization or the standards of care and the language around care is female-focused, men don’t feel comfortable,” Pollack said.
Improving eating disorder treatment for men must be about more than making them feel comfortable speaking out. The medical field must evolve to include men in clinical trials to understand the effectiveness of existing and future medications and therapies among men.
“The provider has to rely on data drawn from predominantly female samples. You have to kind of wing it and assume that the treatment that’s worked for females will work for males,” Murray said.
Until about 10 years ago, the criteria a person needed to meet in order to be formally diagnosed with an eating disorder included loss of menstrual cycle — a physiological impossibility for men.
Changing that criteria opened up new funding opportunities for studying and tracking eating disorders among men, but the field is still catching up.
Less than 1% of studies about eating disorders have involved men, said Murray, who has extensively studied the dearth of resources for men.
Researchers are learning that while influenced by personal circumstance, social media and popular culture, some people may be genetically predisposed to be vulnerable to eating disorders. Future treatments could involve therapies that retrain neural pathways in the brain, essentially reteaching the brain how to think about food and body image.
Clinical studies for these treatments, especially, must include men, whose brains work differently than women’s, Murray said.
“We’re standing at the precipice of repeating history,” he said.
With help from a therapist and dietician, Hornby has established nutritious eating habits and established healthier expectations of his body. In late 2020, he decided to start posting videos and messages on TikTok and Instagram, offering encouragement to people who may not even realize they need it.
He has posted hundreds of short videos with messages like “coffee is not a meal and neither is the milk in your coffee,” “your body isn’t addicted to carbohydrates, it just needs them” and “you aren’t faking your eating disorder if it’s happening when no one’s around” that have earned him hundreds of thousands of social media followers.
He also recorded a song about body dysmorphia - a mental health disorder in which people obsess over perceived flaws with their appearance - he titled “Clay,” he said, “because when you have [body dysmorphia] your mind treats your body like clay,” that can be pinched and molded to a preferred shape.
Sharing such a personal experience is scary and at first, he feared people would think he was making it up for attention, he said. But the messages he receives from others who have found comfort in his posts are encouraging and have helped him maintain his progress.
“Every single day I get messages from people telling me my content is what gave them the push to ask for help…it’s incredibly meaningful,” he said. “It can serve as a reminder that these are not rational thoughts people are having. Then when I have those same thoughts later in the day, it holds me accountable.”
