Think of someone who's suffering from an eating disorder, and a female face probably comes to mind. Unfortunately, this is often true for health care professionals, too, which is why eating disorders among men often go unrecognized and untreated. Believe it or not, 25 percent of those who suffer from eating disorders are male, according to N.A.M.E.D., The National Association for Males with Eating Disorders.

"In the last 10 years, we've seen a rapid increase in eating disorders in males," says Stuart Murray, an assistant professor of psychiatry at the University of California–San Francisco, and director of N.A.M.E.D. "This has to do with more objectification of the male body, and unprecedented pressure for males to achieve a certain body type muscularity like The Rock [a.k.a., actor Dwayne Johnson]. For the first time ever, the rates of disordered eating practices in boys are now increasing faster than they are in girls."

Different Genders, Different Patterns

While members of both sexes experience anorexia, bulimia and binge-eating disorder, the manifestations of eating disorders in guys can be somewhat different than they are in those of the female persuasion. "One of the reasons this is so under-recognized in men is the expectation that [eating disorders] look the same in men and women, and that's not true," says Alison Field, a professor and chair of the department of epidemiology at the Brown University School of Public Health. "An alarming number of young men are concerned with muscularity and are willing to do some potentially unhealthy things, such as taking steroids or using other muscle-building products, to achieve it – I would argue that's the male equivalent of purging."

Indeed, a study published in the August 2016 issue of the journal Pediatrics found that the most gender-conforming young women between ages 13 and 25 were found to have a 50 percent greater likelihood of using laxatives; by contrast, gender-conforming males in this age group had much higher odds than gender-nonconforming males of using muscle-building products. (An interesting exception to this pattern: A 2015 study in Developmental Psychology found that "sexual minority males" – primarily, gay and bisexual males – were more likely than completely heterosexual males to be preoccupied with the leanness of their bodies between ages 17 and 20.)

It's no secret that women with eating disorders tend to have a preoccupation with thinness. Meanwhile, men are often "fixated on muscularity and leanness – which are pretty much mutually exclusive," Murray says. To try to achieve that look, guys with eating disorders often have very rigid eating patterns, with a focus on a high protein intake (they engage in "protein-counting" instead of "calorie-counting," Murray says) and the use of muscle-building supplements. "They are prone to high anxiety if they can't count their protein," Murray says. "They're not afraid of weight gain; they're more afraid of losing weight. A lot of [male] patients will weigh themselves every day so they can get enough protein for what they weigh that day."

Many of them also engage in excessive or compulsive exercise, notes Dr. Casey Cottrill, an adolescent medicine physician at Nationwide Children's Hospital in Columbus, Ohio. "They feel like it's something they have to do. Often it starts with them trying to get healthy and along the way it goes out of control and they become overly rigid and restrained about their eating and excessive about exercise."

A Cascade of Harmful Consequences

Aside from the potential risks associated with taking muscle-building supplements, which are unregulated, there are other health concerns that are unique to men. "I worry a lot about compulsive exercise because sometimes it makes their heart rate go very low," Cottrill says. Indeed, a 2016 study from the University of California–San Francisco found that signs of malnutrition (such as anemia) and health problems (such as slow heart rate) are common in young men with eating disorders. And because men tend to go longer without being diagnosed and treated, "males are at greater risk of cardiac failure and bone loss related to osteoporosis," Murray says. "They go further down the illness trajectory."

Meanwhile, for guys, other harmful behaviors often go hand-in-hand with disordered eating or exercise habits. In a 2016 study, researchers from Boston Children's Hospital and Harvard Medical School examined symptom patterns of eating disorders among males ages 13 to 26 and found that those with high levels of concern about being super muscular have a higher incidence of binge drinking and drug use in the future; the same is true of guys who engage in binge-eating and purging behaviors.

And yet their families and health care providers may overlook many of these harmful patterns. As a result, "a lot of guys get misdiagnosed and their eating disorders are more entrenched by the time they get to a specialty center [for treatment]," Murray says. "Our whole diagnostic system is set up to be female-centric – we're not asking the right questions to identify males who are struggling with this."

The first step is for family members, friends and health care providers to help identify males who are struggling with body image issues and disordered eating behavior, Field says. "You can't always look at someone and know whether they have an eating disorder because it's not visible; it's often hidden." By opening the discussion, it begins to pave the way for a guy to seek help.

To make it easier for men to get into treatment, experts say the entire subject also needs to be de-stigmatized. In fact, many men with eating disorders feel a double sense of stigma about seeking help for what is largely perceived to be a female problem – and this is a barrier to being diagnosed and treated, according to a 2015 study in The International Journal of Eating Disorders. That's unfortunate because effective one-on-one treatment is available for males, Field notes, and group therapy with just men can be particularly helpful. "The most important step to make," Murray says, "is to step into a clinician's office – the earlier, the better."