We don’t always think about men when we think about eating disorders. But in the queer male community, these disorders are quietly at epidemic levels -- gay men are up to three times more likely than heterosexuals to have a clinical or subclinical eating disorder. Statistics from the International Journal of Eating Disorders suggests that 15% of gay or bisexual men have struggled with disordered eating habits throughout their lives, including binge eating, anorexia and bulimia. Of men who struggle with eating disorders, around 42% identify as gay or bisexual. And research shows that eating disorders are the most lethal of all psychiatric illnesses.

If this is such a problem, why aren't more people talking about it? According to Troy Roness, a national eating disorders advocate, speaker and writer for the Huffington Post, the problem is that is subject is still “taboo” among men. “There’s a lack of understanding and education around male eating disorders,” Roness told me, “and the reasons behind that are guilt and shame. I think the notion of having an eating disorder as a male means that you believe you’re perceived as weaker and not able to take care of yourself. It’s hard to reach out and get help when it means that somebody is questioning their masculinity.”

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Roness began to struggle with anorexia at the age of 19, though he'd dealt with body image issues for most of his life. After going through his parents’ divorce and going off to college, Roness claims that he didn’t have “the emotional skills to deal with traumatic events in [his] life.” So as a college student, he decided that he wanted to get healthier and get in shape. For Roness, it was about getting the power back in his life. “When it comes to your interaction with family and friends and your social circle, an eating disorder is a way to control things,” he said. According to Roness, choosing “what you eat and don’t eat becomes controllable but can be controllable in an unhealthy way.”

Although Roness began to drop weight at alarming rates, he didn’t recognize that there was anything wrong. He became so emaciated that he couldn’t stay warm on his own anymore and he recalled wrapping himself in an electric blanket in the living room for body heat. I asked him how he rationalized that to himself -- if he didn’t think he was sick, what did he think was going on? “I felt that I was overworking myself,” Roness responded. “I felt a constant urge to work out. When I looked in the mirror, I saw parts of my body that weren’t muscular enough. They weren’t right and they needed to be fixed.”

As working out became an obsession, Troy Roness reached out for help -- to the "Dr. Phil" show. Roness called in to the program to ask how to “stop working out,” and the show’s producers quickly called him back to book him on the show and start him on the road to recovery. Roness found inpatient eating disorder treatment with all-male units, and many of the patients in his groups were struggling just like he was -- he found out he wasn’t alone. “I was able to relate to straight men and gay men with the same issues, even a 40-something father of three. No matter sexual orientation, age, ethnicity or socioeconomic status, these issues were a struggle for everybody.”

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According to Benjamin O’Keefe, an actor and LGBT rights activist, only one in 10 people with eating disorders will seek treatment. “People do die from this,” O’Keefe reminded me. “Eating disorders have the highest mortality rate of any mental disease. I had to get to rock bottom before I saw how bad it was.” O’Keefe grew up the “chubby” kid, idolizing the men with gaunt cheeks and six-pack abs in Abercrombie ads, and as an actor, he knew he had to fit into that mold. So he came up with a solution he thought was brilliant: don’t eat. “I couldn’t believe no one had thought of it before,” O’Keefe said, with a sad laughter in his voice.

“It started as such a conscious decision, but it was also something I couldn’t control,” O’Keefe continued. “I was suddenly getting all this attention, the kind of attention that I’d never gotten before. I was fitting more into what society thought was ‘normal.’” O’Keefe lingered on this last word. “It’s scary to think that it was so normal to me. I think that’s what people need to understand about eating disorders,” O’Keefe explained. “You could consciously understand that you are dying but you wouldn’t fully understand that you are dying. It’s sad that in our society, some people would die to look a certain way.” At the time, O’Keefe didn’t look in the mirror and see someone who needed help. He just saw the person he was killing himself to be.

After three months, Benjamin O’Keefe lost 80 pounds. He celebrated the weight loss by passing out during the middle of a show. There was no ignoring the problem now.

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O’Keefe couldn’t afford “traditional treatment,” so he consulted therapists and sought the help of friends as he developed a support network for recovery. “It’s important to reach out,” he said. “There are people who are willing to carpool on the road to recovery. There’s help out there. There are people who want you to get better and be the best you that you can be.” For O’Keefe, striving to be his best self meant finally seeing that there was more to him than what he saw in the mirror. “I realized that my life is bigger than a number on a scale,” he said. “My life is meaningful. I found meaning in something other than the way I look.”

Zach Stafford, a writer for Slate and RedEye Chicago, recalled hating his body and how it looked from an early age; he was uncomfortable being shirtless in front of other people. In the Tennessee town he grew up in, there was a strong connection among boys between their bodies and athleticism. He said it was part of the “gender gap.” “Being a young boy in the South, your whole life should be outdoors,” Stafford said, “but it was cool for the girls to stay in.” As a young gay kid, he wanted to be inside with the girls.

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Because he wasn't athletic, Stafford felt there was always a “sense of failure” around his body and how he looked. “If you’re a boy, you need to be fit,” Stafford said. In high school, Stafford became captain of the tennis team to meet the expectation of fitness, but he also began binging, purging and fad dieting. He was surrounded by dieting books -- from South Beach to Atkins -- and with all these pressures, his weight became a “rollercoaster.” “With bulimia, [there are] months where your weight is super down and months where it's up,” Stafford said. “No one noticed until my half-brother saw a picture of me on the front page of the paper. He hadn’t see me in two or three months.”

During that time, Stafford had lost “a considerable amount of weight." It was like his brother was looking at another person.

Stafford’s eating disorder divided his family, but it caused particular tension with his father -- who had always suspected Stafford might be gay. “I wasn’t the boy he wanted me to be,” Stafford explained. “I was effeminate and now I have an eating disorder, which is a woman’s disease. I think there was a lot of fear, fear that I may not even be a boy.” During this time, Stafford’s life became heavily monitored, as he was shipped back and forth to outpatient therapy after school. He drank Pedialyte daily and was forced to sit still on the couch for an hour every day to make sure he wasn’t going off to the bathroom to throw up.

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Even though he sought treatment, Stafford explained that disordered eating is still a reality -- not only in his life but in the lives of those around him. “In the gay community, there are colloquialisms for times when you shouldn’t be eating. 'Pageant season' is a term that people use for summer,” Stafford said. “It’s normalized. We’ve built a community of supporting our disordered eating.” Stafford argued that these messages also pop up in media depictions of gay men. On “Will and Grace,” Jack works for a gay TV network that has purging stations in every bathroom. Growing up, it colored his expectations of what it meant to be a gay man. “I thought that if I’m going to be gay, I have to have an eating disorder,” Stafford said.

Chase Bannister, a psychotherapist who specializes in eating disorders, argued such norms have become the “rule and not the exception.” “The gay male community has placed unrealistic expectations upon itself,” Bannister told me. “Emaciation is normal. Electing not to eat or to only drink liquids for several days has become normative. Negative comments about body weight, shape, size of ourselves or others has become a daily part of our community’s common life.”

According to Bannister, these expectations give men the false and damaging idea that in order to be loved, they need to adhere to an impossible Adonis-like ideal.

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But Bannister argues that these ideas don’t emerge in a vacuum, and if we look to gay men as the source of the problem, we’re missing the bigger picture. Mr. Bannister argues that these disordered habits are a product of “minority stress,” the product of cultural expectations around how a gay man looks and acts. “Gay males have over the years been named by society as having characteristics that are effeminate in nature, which are narrated by culture as weak,” Bannister said, “which as a clinician, I find misogynistic. The result of society seeing effeminate behavior as weak is to get bulked up.”

He also postulated that the movement for perfection was a result of body image issues during the AIDS crisis, where the stereotypical image of infection was “gaunt, thin and vulnerable.” To feel human again was to be fit. This was how people survived. Although fitness has historically offered gay men a measure of protection, both from the internalized stigma of HIV and the physical violence that LGBT people disproportionately face, Bannister explained that it can’t cure the social pressures and shame that act as an “incubator for eating disorders to develop.”

Instead, Bannister believes that, in order to address these issues, looking at isolation may be key. “Interestingly enough, there’s new literature suggesting than loneliness might be a mitigating factor in gay male body image distress,” Bannister explained. “If a gay man is in a romantic relationship, it appears to reduce the remarkable body distress that gay males experience at high rates.” In order to tackle the issue of body image in the gay community, Bannister insists that healthcare providers need to be looking at single gay men, who face “a particular risk for developing eating disorders.”

Bannister believes creating a positive community around body image is no easy task. “It takes a village,” he said. “It’s not only our own self-policing when we hear negative body talk, the helping professions must also step up.” Bannister also argued that the medical community must do more to address the needs of LGBT people, a population that’s sadly underrepresented in medical education. Studies show that the median time reported dedicated to LGBT concerns and content in medical school is five hours -- in total.

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Bannister also mentioned that the research on eating disorders among lesbians and gay men is virtually nonexistent. “It’s a subject that’s tragically and unfortunately under-researched,” he said. “That subgroup, our neighbors and our fellow family members, deserves care.”