"Why Do So Many Men Have Eating Disorders?"

Chris Marvin had a secret morning ritual that he practiced in college. Sunlight creeping through drawn shades, he'd roll out of bed around 7 a.m. with a pounding head. After making sure his door was locked, he'd rummage through drawers and the depths of his mini fridge. Then, on a white marble desk that would have been pristine if not for the Thrasher and Mayhem stickers, he'd line up everything he needed to get through the day.

First, he'd pop a caffeine pill to feel alive; then he'd chase it with a couple of painkillers — a preemptive strike against the grind of training two hours a day, seven days a week. ("There is no rest muscle," he'd tell himself.) A hit from his bong would help calm his racing heart. Instead of water, he'd pour a glass of whiskey to wash down his pre-workout supplements. Then he'd inject himself in either his glutes or deltoids with black market anabolic steroids. After putting his supplies back in their hiding places, he'd ride his bike a half mile from the off-campus house he shared with frat brothers to Sonoma State University in Northern California, where he studied exercise science.

"A kinesiology major doing all that shit? I was a walking oxymoron," says Marvin, now 32. Nothing could keep him out of the gym, not even injuries that would eventually require surgery. "I'd have my training partner hold my shoulder in its socket so I could do heavy preacher curls. In my mind, I was indestructible."

By the time he was 25 and working odd jobs back home in San Diego, Marvin weighed 210 pounds, and his back rippled like the Hulk's. When he eventually cycled off the steroids and ramped up his use of synthetic marijuana, ecstasy, sleeping pills, and Valium — on top of the booze and painkillers — he dropped down to 141 and fell into a deep depression. After one wild bender, he spent more than a week locked down in a psych ward.

"I had done so many drugs that I didn't sleep for eight days coming down off them," he says. "From there, I went to a cognitive behavioral therapy program, and that's where they pointed out that I had muscle dysmorphia. I'd never heard of it before. I was like, 'What the fuck is that?'"

If you look closely, you might see a bit of yourself in Marvin. From a young age, men are taught to be bigger, stronger, and faster, and to fight through pain. Anger? Self-loathing? Anxiety? Who needs a therapist when you have the gym? And who among us hasn't tried to fix our inward insecurities by addressing our outward appearance?
Unlike Marvin, you probably don't have a mental disorder, much less a substance abuse problem that you developed to cope with it. Muscle dysmorphia, or MD, is a little-known psychological condition first described in scientific literature in the late 1990s. Because formal diagnostic criteria define MD as a subset of a broader group, body dysmorphic disorder, it's impossible to know how many people are affected.

But the current diagnostic parameters, such as they are, can apply to millions of people who just aren't satisfied with their physique. Those who suffer from so-called "bigorexia" obsess over their appearance, perceiving themselves to be insufficiently muscular even though they are indeed muscular, if not ripped. "People would give me compliments," Marvin says, "but in my head I was like, 'This part sucks.' I was super insecure even though I looked better than most people. I would almost give myself dry heaves thinking about my body."

"From a young age, men are taught to be bigger, stronger, and faster, and to fight through pain."
The difference between someone with muscle dysmorphia and a regular fit guy is one of degree. Early research in the American Journal of Psychiatry reveals that a typical bodybuilder spends about 40 minutes a day thinking about improving his physique. Those with muscle dysmorphia spend about 325 minutes and check themselves out in a mirror an average of 9.2 times a day. The condition usually takes root in late adolescence or early adulthood, and most guys who exhibit hallmarks of MD have been bullied or shamed about their strength or appearance.

Marvin's case was textbook. In high school, he was 5'11" and weighed around 150. Uncoordinated and nonathletic, he warmed the bench for the basketball team and became the butt of jokes in the weight room. "They laughed at me for being the weakest guy there," he says. "I was a lot smaller than everybody. I was picked on a lot."

Research shows that boys as young as 6 express a desire to be muscular, and that men are more likely to pursue such a physique if they were either teased or received encouragement to do so from parents or peers. And beyond their inner circle, men face constant pressure to look a certain way.

We see it in movies: Mark Wahlberg isn't the world's highest-paid actor because of his Boston accent. We see it on TV: Fat guys like Kevin James always play the fool. We see it in advertising: Quick, what's an underwear model look like? We see it in magazines: Even at Men's Health, we sell it on our covers. We see it in dating apps: How are you framing your Tinder profile? We see it in social media: The Rock has 100 million Instagram followers. We see it in video games: Research shows that men have lower self-esteem about their bodies after using very muscular avatars. We see it in toys: In the late 1990s, G.I. Joe Extreme action figures were pumped up to have the real-life equivalent of a 55-inch chest and 27-inch biceps.

"When we see images of muscular bodies, which we are bombarded with, we become less satisfied with our own," says Stuart Murray, Ph.D., a clinical psychologist at UC San Francisco. "The established norm is unrealistic in a lot of ways. A lot of the idealized images we see are Photoshopped and by definition impossible to replicate. And models often do extreme dieting for a photo shoot."

The ideal male body in pop culture has a V-shaped torso, big arms, broad shoulders, a flat stomach, and a small waist. In one study, nine out of 10 college-age men expressed a desire for greater muscularity. In yet another, more than 90 percent of adolescent males reported exercising to look more muscular; two-thirds altered their diet to increase their muscle size or tone; and nearly 6 percent admitted to using steroids, which are now also viewed as appearance enhancers instead of just performance enhancers.

A few months before Marvin started at Sonoma State in 2008, he had a vision not so much of who he wanted to be but of what he wanted to become. "I had these fantasies like all guys have. I wanted to be big, buff, ride a motorcycle, get chicks, be athletic," he says. "I was none of those things." So he started working out, but didn't know what to do in the gym or how long getting buff was supposed to take. A few months in, he bought steroids from an acquaintance and learned how to inject them from a classmate's mom, a nurse who gave him syringes that she took from her hospital.

"I was 21 and a half. My testosterone was as high as it was ever going to be. I decided it wasn't good enough," he says. "I wanted that quick fix. And, of course, I put on 30 pounds and was like, 'Holy shit, this is awesome.' The feelings of power and confidence were pretty incredible. The drugs allowed me to be what I wasn't. I felt smarter, I felt more confident, I felt sexier. I felt at ease."

But the steroids didn't address the underlying pathology of muscle dysmorphia, which led Marvin to focus obsessively on his perceived flaws. "I wouldn't take my damn shirt off because I was so embarrassed about my chest," he says. "Instead of being like, 'Dude, check it out, my arms are growing, my legs are growing, my back is growing,' I would zero in on my chest and be like, 'Oh my god, I'm pathetic.' I only focused on my inadequacies."

"I contemplated driving my car off the road every day for about two years."
Marvin checked off almost every box for symptoms and associated behaviors of muscle dysmorphia. Mood swings? "If you cut me off in traffic, I'd get angry because I assumed you did it on purpose." Depression and anxiety? He lived in a state of "general discomfort just below panic," especially around muscular guys. OCD tendencies? "I'd do a flex routine in the mirror every day and focus on my weaknesses." Impaired social functioning? "I was incapable of being around people without at least being stoned on marijuana. I needed that buffer to feel okay about myself." Some of his symptoms were associated complications of MD: Substance abuse? "At the inpatient program, they told me I was the most advanced drug user they'd ever met." Suicidal thoughts? After a bad breakup, he says, "I contemplated driving my car off the road every day for about two years."

When he stopped taking steroids in 2013, he faced a new problem: His body no longer produced testosterone naturally, a condition known as anabolic steroid-induced hypogonadism, or ASIH. He now uses a prescribed androgen cream every morning, rotating between sites on his forearms and upper torso. (His girlfriend can't touch the active site for hours to protect her hormonal balance. Even a hug could do harm.) Because of the damage to ligaments and tendons from his insane workout regimen and steroid use, he wakes up to aches and pains in just about every joint.

"I fucked my body up for the rest of my life," he laments. "Part of my therapy was realizing that my outsides do not define my insides. I would assign my morality based on how my body looked, how my workouts went, and what I ate that day."

Eating disorders are another hallmark of muscle dysmorphia. Bulking up requires a high-calorie diet, but even with anabolic steroids, it's extremely difficult for an experienced, genetically maxed-out lifter to do a "clean" bulk — a term for building muscle without also adding fat. The quest to get bigger while staying shredded leads to bizarre diet choices, with grossly inadequate levels of vitamins and minerals.

"Guys can look amazingly healthy, like Greek statues, and yet they're very compromised medically," says Murray, who is also codirector of the National Association for Males with Eating Disorders. "You can end up with a dangerously low heart rate and electrolyte imbalances."

Clinicians identify three main types of disordered eating. Anorexia is calorie restriction; bulimia is purging calories by regurgitating food, using laxatives or diuretics, or exercising to cancel out intake (or a combo of these); and binge eating is losing control, eating when not hungry, or consuming excessive amounts at one time.

Though eating disorders and muscle dysmorphia are listed separately in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, current research views them as a constellation of related behaviors. Both are the direct result of over-evaluating an idealized body type, which fuels either a drive for leanness, a drive for muscle mass, or both. These body image disturbances can give rise to disordered eating behaviors — an issue rarely talked about in the lives of men.

"There's a double stigma in males," says psychiatrist Brad Smith, M.D., medical director of eating disorder services at Rogers Behavioral Health, a treatment facility with branches nationwide. "There's the stigma of having a psychological or psychiatric issue. It's hard to get men to seek treatment even for depression. On top of that, this is typically characterized as a women's illness.""Society has trained us that we are strong, masculine figures who don't really think about that kind of thing," says Dan Stein, 35, a strong, masculine figure who nearly died from that kind of thing.

Two weeks before he left home for the University of Minnesota in 2001, Stein weighed 215 pounds, thanks to years of McDonald's runs, sugary sodas, and junk food. "My parents called me husky," he says. "Dad bod, that's probably the most accurate description of where I was at." Determined to get in shape, he began running 6 miles a day, five days a week, and occasionally lifted weights in the school's gym. By the time he returned home for winter break, he was down to 185 and, he says, "everyone told me how great I looked. It was an ego boost." By the end of his second semester he weighed 165. "I did the freshman minus-50. But I was skinny-fat. I didn't have muscles or much definition."

"Society has trained us that we are strong, masculine figures who don't really think about that kind of thing.
A turning point came early in his sophomore year. Shirtless, Stein was throwing a football around with some friends on a grassy field near his apartment. Members of the school's football team, also shirtless, happened to pass through. "Some very attractive girls went over and started talking to them," Stein says. "In my head I was like, 'I've been working out like crazy. What can I possibly do to look like these guys and get that attention?'"

Stein thought the problem must be his diet. He wasn't getting shredded, he figured, because he was eating too much. In truth, he was eating too little to gain muscle. Misguided about how the body works, Stein's diet became so restrictive that breakfast was a handful of Special K Protein or Honey Bunches of Oats. For lunch, he'd eat a small can of tuna and half a cantaloupe. Dinner was a bag of microwave popcorn or a protein bar. All the while, he was running up to 50 miles a week and lifting weights three times a day for 90 minutes a session. He'd often wake up at 2 a.m., do 45 minutes on the stair climbing machine in his building, and then go back to sleep. He was consuming some 1,000 calories a day and burning around 4,000, and says he "started getting weaker in the gym."

Stein skipped so many classes to hit the gym that he failed out of school. He moved back in with his parents in Wisconsin and began waiting tables at a local steakhouse. Each night, he brought home the same dinner — pasta with marinara — and locked himself in his room so no one could see him swallow the marinara sauce and spit the noodles into the trash. He allowed himself just one real meal a year, Thanksgiving dinner, but only after running a solo half marathon in the morning. His exercise was so compulsive that he once ran in minus-10-degree weather. He was so obsessed with his body shape that he'd spend up to 15 minutes agonizing over which bottle of diet soda to drink: one that had five calories, or another that had 10.

"I was one of those ignorant people who thought the only way you burn calories is by working out," he recalls. "I didn't know that eating food is burning calories. That breathing, every function of our body, burns calories."

At his lightest, the 5'10" Stein weighed just 132 pounds. He had sunken eyes, emaciated cheeks, and cold fingers and toes. The summer before his senior year of college (he eventually got his grades up at a technical school and finished at the University of Wisconsin-Milwaukee), he visited his older brother in Georgia. Though it was 90 degrees out, Stein wore a t-shirt, sweatshirt, and two pairs of sweatpants. His fingernails were blue, his lips purple. On the way to lunch, he asked his brother's fiancee to turn the heat up in the car. "She looked at me like I was insane," stein says. "My hands were ice cold. I started to think I had something physically wrong with me. Did I have cancer?"

A doctor back in Wisconsin told him he had 20 signs of starvation. "That's when I had the realization I was anorexic," he says. "My family always knew I had an issue, but they skirted around it, and I just pushed it aside. My body was in decay, and it really hit home that if I didn't change something soon, this could kill me."

Eating disorders affect men of all ages, races, ethnicities, and sexual orientations. It's estimated that 10 million men in the United States will be affected at some point in their life by eating disorders, which have the highest mortality rate of any mental disorder.

"We need to educate people on what to look for and how to speak to our children," says psychotherapist Andrew Walen, L.C.S.W.-C, founder of the Body image Therapy Center in Maryland and president of the National Association for Males with Eating Disorders. "It's not about beauty. It's about what makes you special — your humanity, your empathy, your kindness. These are the messages we need to give our young men, rather than 'Are you the best? Are you the strongest? Are you the fittest?' We've got to tell them that their body is their home. It's not their billboard."

Multiple eating disorders can overlap in people, and men with muscle dysmorphia often cycle through behavioral symptoms of all three; even a cheat meal can be considered binge eating if it causes mental distress. Early warning signs that your body might be compromised include dehydration, a slower heart rate, low blood pressure, and reduced body temperature. Compounding the problem: Doctors don't always know what to look for in men.

Case in point: Walen recalls being approached by the parents of a 14-year-old boy who had lost more than 20 percent of his body weight in three months. He had become fixated on running, biking, and lifting weights, and he'd also become emotionally disconnected. "This is a classic case of a young adolescent male with an eating disorder," Walen told the parents. "Let's get labs to make sure he's not medically compromised." But the teen's primary-care doctor didn't believe it. He patted his patient on the belly and said, "He looks fine. I wish I had abs like that." When the blood work came back, it showed failing kidneys and compromised liver enzymes.

Walen, 45, might understand male eating disorders better than anyone. He was a patient before becoming a therapist. In 1997, an MRI revealed that compulsive running had reduced his left hip socket to bone-on-bone. Afraid he'd need a hip-replacement surgery before age 30, he began lifting weights. If he couldn't be as thin as he wanted to be, he figured he'd make himself as muscular as possible. He lifted so obsessively that he tore his rotator cuffs and labra in both shoulders. "That is absolutely a male experience of eating disorders, muscle dysmorphia, and body-image disturbance," he says.

Hoping to find support, Walen attended a conference on eating disorders, but he felt out of place when he realized the other men in the room were fathers of young girls with eating issues. The only book that connected with him, Making Weight, focused on anorexia — wrestlers, boxers, MMA fighters, distance runners, and gymnasts are especially at risk — and didn't address the spectrum of his experiences, particularly binge eating and compulsive lifting. So, in 2014, he wrote and self-published Man Up to Eating Disorders, to "normalize the experience and create a tribe of recovery."

It's vital work. By the time a man admits he has a problem and gets past his reluctance to seek help, the damage is often perilously advanced. One study found that between 1999 and 2009, the number of men requiring hospitalization for an eating disorder increased 53 percent, more than double the increase in women. "There's a mistaken belief that this is rare and that men who suffer from these are atypical, emasculated, or weird," Murray says. "We have to shift that gym culture."

Dan Stein calls it a "fascinating miracle" that he didn't die or suffer long-term complications from his battle with anorexia, which lasted nearly five years. His recovery included a few sessions with a therapist but was largely a self-guided education. "I learned as much as I could about the human body," he says. "How it survives, how it works, fitness, nutrition, health — literally everything I could get my hands on."

Stein now lives just outside Los Angeles and works for a social media company a few blocks from Muscle Beach. Five days a week, for no more than 75 minutes, he pumps iron at the original Gold's Gym. "I'm surrounded by some of the most fit, attractive human beings on the planet," he says. "There are moments where you think, 'Good god, I wish I looked like that guy.' But I push those thoughts out and they don't derail me."
He limits his cardio to 30 minutes a week, he says, "because I don't want to lose weight anymore, and I associate cardio with losing weight."

He maintains his 180 pounds and 9 percent body fat by eating six meals day, including lean protein (chicken, egg whites, fish), complex carbs (sweet potatoes, quinoa, whole wheat pasta), fruit (blueberries, apples), vegetables (asparagus, broccoli), and healthy fats (coco nut oil, almond butter, olive oil). He even has an occasional slice of cheesecake.

"I thought I was genetically dealt a bad hand," he says of his old mindset. "When I started to understand that my body doesn't act different from 99 percent of the public, I realized it wasn't physical; it was mental. I know now that I bring so much more to the table than just how I look."

Chris Marvin has experienced a similar transformation. The man who once popped 68 Percocets in less than 72 hours now attends 12-step fellowships at least three times a week. "My brain got me in the mess I was in, so I shouldn't be trying to figure this stuff out alone," he says. "I air stuff out."

Marvin has been clean and sober since completing an intensive, three-month behavioral modification program five years ago. His new morning routine includes drinking a cup of coffee and saying a prayer that he wrote after finishing the program. It includes this line: "Relieve me of my fear and insecurity, and replace it with self-love and acceptance."

Marvin named his personal-training business One Rep at a Time — a nod to overcoming addiction one day at time and to building genuine muscle over months and years. Some of his clients are also in recovery, and Marvin shares his struggles with them openly. "I feel like I've finally found my calling," he says.

To put himself in the right mindset in the gym, Marvin listens to epic, intense battle music that "makes me feel like I'm saving the world." He doesn't swear at himself anymore, and he'll frequently reset his body and mental focus with deep-breathing exercises. "I used to think that everybody who was a workout junkie would give themselves high blood pressure from being so angry," he says. "My old workouts were a way to punish myself. I do this now as a way to improve myself."

But Marvin knows what lurks in the background, waiting for a chance to consume his life once again. Every time he posts a shirtless photo on Instagram — a tried-and-true marketing strategy for personal trainers, but a risky one for someone recovering from muscle dysmorphia — he worries about triggering old insecurities or introducing new ones to his clients and followers. "My recovery is fluid," he says. "It will always be a balancing act."


Do you have an eating disorder?
Consider these statements from a 50-question eating disorder assessment designed specifically for men. Choose one of six responses — never, rarely, sometimes, often, usually, or always — as it applies to the following statements. Answering "always" to these and other statements suggests you may have a problem.
This article originally appeared on www.menshealth.com