Culture and Eating Disorders: A Singaporean Perspective — Part 2

I previously looked at two retrospective studies of anorexia patients in Singapore, which primarily concerned female patients. In this study, Tan et al (2014) looked at 72 male-identified patients diagnosed with all forms of eating disorders.

  • 1% had anorexia nervosa (15.3% binge-purge subtype, 20.8% restrictive subtype)
  • 3% had bulimia nervosa (27.8% purge subtype, 5.6% non-purge subtype)
  • 5% had EDNOS
  • 9% had BED

The mean age at intake was 19.9 years old; patients were mainly students (41.7%) and national servicemen (41.7%). Compulsory army service (National Service) usually takes place in the two years after high school graduation, though some may defer until completing further studies. The typical age range for those in National Service is 19-24.

Of the patients in the study, 88.9% identified a precipitating factor for their eating disorder, including being overweight (59.7% reported pre-morbid obesity) and having people make comments about their body. 68.1% of patients also acknowledged body image issues, particularly around their abdomen. 66.7% engaged in excessive exercise.

If you look at these statistics, you can see an illness pathway that is distinct from the female patients I wrote about in my last post: many men in the sample reported a history of obesity and noted that this was a trigger for their eating disorder. The authors caution that this could be either because disordered eating patterns lead to both obesity and eating disorders, or because obesity itself acts as a trigger for subsequent disordered eating.

Further study would be needed to know whether disordered eating existed before patients’ obesity. It would also be interesting the development of the eating disorder meant diagnostic crossover from BED to AN, the opposite of what tends to occur in female patients (who tend to move from restrictive to binge-related behaviors). Another possible explanation for the higher rates of obesity in male patients (versus female patients) is that weight stigma contributing to the onset of EDs kicks in at a higher weight for males – in other words, men’s bodies are labelled as excessive at a later stage of weight gain than women.

This higher starting weight of male patients may be a reason why they had a longer duration of untreated illness: 3.0 years on average, versus 1.39 in Kuek et al (2015). The authors also note that men may only be diagnosed when there is another co-occurring psychiatric disorder (Bramon-Bosch et al., 2000). In their study, 61.1% of the men had other psychiatric conditions whereas only 31.7% of women did. I think the correlation can go either way, though; it could also be that there are specific cultural factors that protect against EDs in men. Either way, though, the authors highlight barriers to treatment as a particular concern with male patients.

Lee et al (2005) found a more even distribution of referrals compared to this study, with many more coming directly to the ED services. However, most male referrals came from hospitals (68.1%); only 12.5% referred themselves. Before entering ED services, 37.5% had received prior treatment from other professionals. Though we don’t have similar numbers on treatment effectiveness and relapse for female patients, this points to the difficulty of accessing specialist services for males in particular – whether this is due to under-recognition of eating disorders in men or lower severity is unclear. The authors did not report BMIs at intake, so it may be that primary care settings were less likely to refer men as they had fewer medical complications. By the time they were referred to the EDTP, though, quite a number of patients were severe enough to need inpatient treatment (37.5%, consistent with other studies).

The high number of males referred during National Service in particular is interesting – Lee (2005) found similar gender-specific clusters in all-girls schools. Mensinger (2001, p.426)’s paper on this topic suggests that ‘the presence of males may actually mitigate a female’s distorted body image’ and Mensinger (2004, p.30) similarly shows that ‘gendered social climate of a school leads to greater disordered eating’. While she does not have similar findings for all-male environments, these findings suggest some form of gender-specific environmental influences on eating disorders.

In the case of the army, the disciplining of overweight bodies and the emphasis on physical fitness can be a trigger for those pre-disposed to eating disorders. For example, I’ve heard from enlisted soldiers that overweight recruits can be confined to barracks if they fail to meet weight loss targets, and recruits who fail to pass their physical fitness test must enlist earlier. Being in the army might make engaging in unnatural weight-control measures easier and more ‘normal’; for example, excessive exercise would be rewarded rather than seen as cause for concern. Such processes were probably also at play in the number of cases seen in Lee et al. (2005) who identified participation in the Trim and Fit program as a precipitating factor.

If eating disorders in both females and males tend to arise in single-gender environments, should treatment equally differentiate between genders? This paper’s authors note the problems faced in this regard in dealing with a ‘feminine’ disorder, suggesting that:

treatment services could start by striving to be more gender sensitive, rather than aim to be gender specific. For example, psychological interventions could do more to address issues such as stigma and gender identity, arising from being afflicted with a “woman’s disease”. The therapeutic milieu could be enhanced by engaging more male staff, to facilitate group therapy discussions on male concerns. Physical recovery could also be aided with nutritional rehabilitation that is more sensitive to the dietary demands unique to the male body. (p.80)

Their distinction between ‘gender-sensitive’ and ‘gender-specific’ is useful here, and I would also add ‘gender-segregated’. This isn’t available in Singapore, although psychiatric wards are separated by gender (albeit with common occupational therapy groups). Some might argue that the correlation between gender-segregated environments and ED rates implies that treatment environments should not be segregated. I can see how some patients might do better in single-gender settings for individual reasons – and, equally, vice versa (see this post on interpretations of therapists’ bodies).

Truly ‘gender-specific’ treatment is an illusion – I doubt that anyone can isolate valid ‘male’ and ‘female’ protocols given how slippery and diverse each category is. However, as the paper suggests, gender-sensitive treatment would be a more realistic goal. I’d think any good treatment center should provide gender-sensitive services, as an extension of individualized treatment protocol and the recognition that therapeutic and nutritional needs will differ within and between genders. A big question that the authors raise is the idea of eating disorders as a ‘feminine’ disease, though – to what extent do treatment providers design and deliver interventions with a female audience in mind, consciously or unconsciously?

A more effective approach to such services would require a firmer understanding of the gender-dependent components of eating disorders – something that is still not well understood. Without getting into a whole other area of research, several studies point to a possible role of gender dysphoria and non-heteronormative identity in eating disorders, including

  • Algars (2012)’s finding amongst a small sample of Finnish adults that “gender reassignment was primarily perceived as alleviating symptoms of disordered eating”,
  • Feldman and Meyer (2007)’s study with non-heterosexual-identifying men reporting higher rates of eating disorders, and
  • Austin et al (2010)’s results showing non-heterosexual adolescents of both sexes engaging in more bulimic behaviors than heterosexual adolescents.

However, the real factors at work here remains unclear – how gender and sexuality is learnt and transmitted is really hard to pin down without essentializing the processes in question.

Whether or not eating disorders have their roots in these issues, I think that the process of recovery necessarily involves asking these questions. Judith Butler’s work in Gender Trouble and elsewhere argues that we should understand gender as performative (here’s a quick explanation) – in other words, gender is not a static identity but a constant process involving both our self-image as well as other people’s interpretations of how we perform gender. I would suggest that recovering individuals necessarily experience their gender differently in light of their changed relationship to a (necessarily gendered) body. This change is especially difficult to grapple with in the face of dominant social norms that come into conflict with what we learn about recovering bodies. Unlearning these norms can be a part of growth in recovery, but can also be an additional hurdle to recovery.


Ee+Lian&;bpr3.tags=Medicine%2CCancer%2C+Hematology">Ming, T.S., Shan, P.L.M., Cen, A.K.S., Lian, L.E., & Kim, E.B.S. (2014). Men Do Get It: Eating Disorders In Males From An Asian Perspective. ASEAN Journal of Psychiatry, 15 (1), 72-82

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Jacqueline is a sociology undergraduate student from Singapore with an interest in mental health and illness, bodily work, and their intersections with the political. She is currently in recovery.

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