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ORIGINAL ARTICLES |
From the Division of Epidemiology and Community Health (D.M.A.), School of Public Health, University of Minnesota, Minneapolis, Minnesota; Eating Disorders Institute (G.F.), Methodist Hospital, St. Louis Park, Minnesota; Division of Epidemiology and Community Health (D.N.-S.), School of Public Health, University of Minnesota, Minneapolis, Minnesota; and Performance Measurement and Analysis Department (H.R.B.), Allina Hospitals and Clinics, Minneapolis, Minnesota.
Address correspondence and reprint requests to Diann M. Ackard, 5101 Olson Memorial Highway, Suite 4001, Golden Valley, MN 55422. E-mail: Diann_Ackard{at}mindspring.com
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ABSTRACT |
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Method: Data were collected from 10,095 9th and 12th grade Minnesota Student Survey participants who reported sexual intercourse in the past year.
Results: The use of any disordered eating behaviors was reported by 39.4% of the sexually active males reporting only female sex partners, 53.4% reporting only male sex partners, and 56.4% reporting both female and male sex partners. Rates of specific disordered eating behaviors were associated with higher numbers of sex partners (male and/or female) and same gender of sex partner, and were highest among those males who reported 3 or more of both genders of sex partners. Among sexually active males reporting disordered eating, poorer emotional well-being and less family connectedness were associated with greater number of partners and with same-sex partners.
Conclusions: Sexually active males, especially those with multiple and/or same-sex partners, may benefit from interventions targeted at reducing disordered eating behaviors. Among sexually active males engaging in disordered eating behaviors, enhancing emotional health and improving family connectedness may be beneficial, especially among those with sex partners of the same gender and/or with multiple sex partners. The identification of specific psychosocial characteristics that are commonly associated with sexually active adolescent males and who exhibit disordered eating behaviors may provide direction toward the development of appropriate early identification, prevention, and treatment efforts.
Key Words: male sexual activity • disordered eating • self-esteem • emotional well-being • family connectedness
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INTRODUCTION |
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Disordered eating behaviors among males are commonly associated with several other behavioral and emotional problems, as noted by Keel and colleagues who studied a small school-based sample of boys and reported that disordered eating behaviors were associated with body dissatisfaction and depression (4). Investigators of a large national survey reported that approximately 7% of boys reported disordered eating and 20% reported (ever) dieting, and that these behaviors were associated with lower self-esteem, greater depression, and greater suicidal ideation (5). Similarly, among a clinical sample of individuals diagnosed with bulimia nervosa, Soundy and colleagues reported major depression in 51.2% and alcoholism in 15.5% of males with bulimia (6). In addition to the association between disordered eating and related psychopathology, research has indicated that familial problems may factor into the development of eating disorders. Kinzl and colleagues found that past physical abuse and adverse family background were associated with higher risks for the development of eating disorders in male college students (7). Thus, several identified psychopathological and familial factors are associated with disordered eating behaviors among males.
To add to the complexity of understanding disordered eating behaviors among males, several studies suggest that males engaging in homosexual/bisexual activities are at higher risk for practicing unhealthy weight control behaviors compared with males of heterosexual orientation. For example, a study comparing homosexual and heterosexual men found that homosexuality was associated with higher severity of bulimic behaviors compared with heterosexual men (8). Similar results have been found among adolescents. In a large population-based study, Lock and Steiner found that mean scores for eating problems (including dieting, body image, and binge eating) were significantly higher in male and female adolescents who were identified as gay, lesbian, and bisexual (9). More specifically, in a recent longitudinal study of adolescent boys in the United States, gay and bisexual boys were found to be more likely to want to look like boys and men in the media, and were 15 times at greater risk for binge eating compared with heterosexual males (10). Similar associations between homosexuality, disordered eating, and related concerns have been reported in previous studies of adolescent males (11,12) and adult men (13–15).
Of clinical significance is that there are reported associations between homosexual orientation and full criteria diagnoses of eating disorders. For example, Schneider and Agras reported that 2.1% of homosexual men had an eating disorder, compared with only 0.3% of heterosexual males (14). Investigations of patients diagnosed with eating disorders have reported that 27% of 135 male patients with eating disorders exhibited homosexuality/bisexuality (16). Furthermore, 12% of 25 college men with eating disorders were identified as homosexual, compared with 4% of a comparison group of 25 college men without eating disorders (17).
Other studies reported findings on the association between sexual orientation and mental health concerns. For example, in a large representative sample of >4000 male and female youth, researchers found that homosexual orientation was associated with suicidal ideation and attempts and substance use (18). Homosexual men have reported greater body dissatisfaction and depression and lower self-esteem than heterosexual men (8). Furthermore, gay youth have been found to report increased social anxiety, depression, and suicidality (19), distress in their family environment (20), and harassment or violence at school (21).
In the literature on eating disorders, ample evidence suggests that certain personality traits and characteristics are associated with eating disorders (22). Although the research on males is scant, there is strong evidence among females that a myriad of impulsive behaviors, including sexual promiscuity (23), are associated with disordered eating, particularly behaviors more consistent with bulimia nervosa or purging/compensatory behaviors. For example, a study of clinician description of a patient with an eating disorder found that sexually impulsive behaviors could be predicted by a personality characterized as undercontrolled and emotionally dysregulated (24). It is reasonable to assume that some of the multi-impulsive personality profiles found among females would also hold true among males.
Further research needs to be conducted on the prevalence of disordered eating and psychosocial factors that may contribute to the development of disordered eating behaviors among males. The aims of this study were to a) describe the prevalence of disordered eating behaviors in a large, statewide, population-based sample of sexually active adolescent males, b) determine the use of disordered eating behaviors by gender of and number of sex partners, and c) identify psychosocial correlates of these sex behaviors among males reporting disordered eating. We hypothesized that disordered eating would be higher among males with multiple partners and those engaging in same-sex activities than among males with fewer partners and/or those engaging in heterosexual activities, and would be highest among males having multiple male sex partners. We also hypothesized that adolescent males engaging in disordered eating behaviors and same-sex sexual activities would report lower self-esteem, poorer emotional well-being, and less family connectedness than adolescent males engaging in disordered eating without same-sex sexual partners.
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METHODS |
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The 121-item self-report survey includes questions on health and safety, environmental influences, school and personal characteristics. Most items have been used in other large surveys such as the Minnesota Adolescent Health Survey (26,27), the National Institute on Drug Abuse Monitoring the Future Survey (28), and the National Youth Risk Behavior Survey (29).
The survey for the 9th and 12th grade students also contains questions on disordered eating behaviors and sexual activity. Because sexual activity and disordered eating behaviors were instrumental variables in the study and were not included in the 6th grade survey, 6th graders were not selected for inclusion in the study. A total of 41,044 males in 9th and 12th grade completed the survey, from which the 10,095 male subjects who reported having had sexual intercourse at least once (with male or female sex partner) and who completed the survey in its entirety were selected. Because an important aim of the current study seeks to understand the association between same-sex sexual activity and disordered eating among adolescent males, boys who did not report any sexual activity were excluded so that the comparison group is of sexually active males who only reported sexual activity with females.
The 10,095 students included in the current analysis were: White (82.9%), Black (6.7%), Asian (4.3%) or reported some other race or a mixture of more than one race (6.1%). The mean ± standard deviation age of the selected subjects was 16.7 ± 1.5 years (range = 13–19 years). Participation in the survey by the school district and the student was voluntary. Eighty-eight percent of school districts within the state chose to participate in the 2004 Minnesota Student Survey (this represents 75.1% of 9th grade students and 55.3% of 12th grade students in Minnesota who chose to participate in the survey).
Measures
Sexual Activity
Sexual activity was assessed using the question, "Have you ever had sexual intercourse ("gone all the way")?" Those who answered "yes" to this question were selected for inclusion in the current study. Same-sex activity was assessed by asking, "During the last 12 months, with how many different male partners have you had sexual intercourse?" Response categories were none, 1 person, 2 persons, 3 persons, 4 persons, 5 persons, or 6 or more persons. These categories were then collapsed into None; 1 to 2 male sex partners; or 3 or more male sex partners.
Disordered Eating
Disordered eating was defined as laxative use, diet pill use, vomiting, smoking, and fasting and/or skipping meals to lose or control weight, or engaging in binge-eating behavior. To assess unhealthy weight control behaviors, participants were asked, "During the last 12 months, have you done any of the following to lose weight or control your weight?" and could mark "yes" to as many of the following as applied: fast or skip meals, smoke cigarettes, use diet pills or speed, vomit (throw up) on purpose after eating, and use laxatives. Binge eating was assessed with the question, "During the last 12 months, have you ever eaten so much in a short period of time that you felt out of control (binge eating)?"
Self-Esteem
Self-esteem was measured with a seven-item scale adapted from the Rosenberg Self-Esteem Scale (30) that assessed personal satisfaction, pride, worthiness, abilities, and feelings about self. Each question had four Likert-type responses ranging from "disagree" to "agree" and the total scale score ranged from 7 to 28. Responses were averaged across items, with higher scores representing higher levels of self-esteem (
= 0.87).
Emotional Well-Being
Emotional well-being was assessed using a set of six survey questions examining mood, stress, sadness, hopelessness, nervousness, and satisfaction with self over the last 30 days. The scale score was the mean across items, with higher scores representing a higher emotional well-being ( = 0.84). The total emotional well-being score ranged from 6 to 30. Internal consistency (Cronbach’s ) was found to be 0.84 (Cronbach’s ).
Family Connectedness
Family connectedness was measured with seven questions about whether or not adolescents felt they could talk to their mother and/or father about problems, their perception of how much their parents care about them, and the extent to which they believe their family cares about feelings, is understanding, has fun together, and respects privacy. The scores ranged from 7 to 35, with higher average scores indicating greater family connectedness. Internal consistency reliability was good ( = 0.86).
Data Analysis
Data were analyzed using the Statistical Package for the Social Sciences software (SPSS, version 14.0; SPSS Inc., Chicago, IL) (31). First, participants were described by frequencies and percentages of sexual activity by gender of and number of sex partners. Then, participants were grouped by gender of partner and by number of sex partners (none, 1–2, or 
3) to evaluate differences in use of disordered eating behaviors by gender of and/or number of sex partners, using the 
2 test to measure statistical significance. As there were no significant differences by group (gender of and/or number of sex partners) on age or race, analyses were run without controlling for these demographic variables.
To identify psychosocial factors related to the gender of sex partners and disordered eating, study participants were categorized into three groups: a) use of disordered eating behaviors and only female sex partners, b) use of disordered eating behaviors and only male partners, and c) use of disordered eating behaviors and both female and male partners. A second set of analyses investigated psychosocial factors related to disordered eating and number of sex partners, using the following groups: a) use of disordered eating behaviors and only one to two female and/or one to two male partners and b) use of disordered eating and three or more female and/or three or more male partners. Analysis of variance was used to evaluate differences by group for each psychosocial characteristic. For all group comparisons, Tukey’s multiple comparison tests were conducted post hoc to assess differences between pairs of groups at p 
.05.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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Among the sample of sexually active males used in the current study, fasting (18.5%), smoking to control weight (14.8%), and binge-eating (21.2%) were the most commonly reported disordered eating behaviors, followed by diet pill use (5.8%), vomiting (4.0%), and laxative use (3.9%). Disordered eating behaviors were most prevalent among the adolescent males who reported same-sex sexual activity. Any disordered eating was reported by 53.4% (n = 78) reporting only male partners and 56.4% (n = 616) reporting both male and female sex partners, compared with 39.4% (n = 3435) of those reporting only female partners (2 = 123.1; p < .001).
Disordered eating behaviors were associated with greater number of sex partners. As shown in Tables 1 and 2, there were differences by number of partners on the percentage who reported disordered eating behaviors, with those reporting a greater number of sex partners reporting more use of any disordered eating behaviors. Overall, a higher number of sex partners, irrespective of gender of sex partner, was associated with greater use of diet pills and laxatives. For males with only female sex partners, and those with both male and female sex partners, higher numbers of sex partners were also associated with smoking to control weight, vomiting, and binge-eating, but not with fasting.
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A similar pattern was seen in analyses of the number of sex partners on psychosocial factors among those sexually active males with disordered eating behaviors (Table 4). Sexually active adolescent males with 3 sex partners, regardless of gender of the partner, scored lower on measures of emotional well-being and family connectedness, and higher on a self-esteem scale, than their peers with one to two sex partners.
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DISCUSSION |
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Several hypotheses exist to elucidate the associations between same-sex sexual activity and disordered eating behaviors among boys. First, predominant gay culture emphasizes a slender body shape, and consequently, societal influences may be similar to that known as the cultural ideal for heterosexual females (15,32). Second, there continues to be stigma associated with same-sex relationships (32). The discomfort associated with homosexual orientation may cause significant distress and consequently increase the likelihood for maladaptive coping strategies, such as disordered eating (32). Previous research has suggested that some disordered eating behaviors (such as binge-eating and purging) have been found to be a means, albeit a destructive one, of managing strong affect among females (33,34), and this may be true among male populations as well. However, these cross-sectional data are inconclusive as to whether these associations exist as part of identification of gay/homosexual culture, are related to a greater body of risk-taking behaviors, or are relevant to other factors not investigated in the current study.
Regarding the association between disordered eating behaviors and number of sex partners among sexually active males, it is possible that the association between number of sex partners, irrespective of gender of the partner, and disordered eating and weight-control behaviors among males is similar to the pattern of multi-impulsive behaviors among females. Researchers have wondered whether individuals with eating disorders, most often those with bulimia nervosa, who also engage in other impulsive behaviors should be classified diagnostically in a different manner, such as "multi-impulsive bulimia" or "impulsive personality disorder" (23), both diagnoses of which are unavailable within the current nosological classifications. Although it is inconclusive to state that more than one sex partner is synonymous with impulsivity, the combination of multiple sex partners and disordered eating and other weight-control behaviors may be suggestive of poorer impulse control.
Among males engaging in disordered eating, males engaging in same-sex sexual activities had increased risk for poor emotional well-being. This finding is consistent with other studies that have documented that gay adolescent males may be at risk for emotional distress (35,36). Of further concern is that suicide rates among the adolescent gay population are approximately two to three times higher than those of their heterosexual counterparts (37). The negative social stigma associated with being attracted to other males may be one reason for the lower emotional well-being in this population. Furthermore, males with greater femininity—a trait associated with disordered eating behaviors (38,39)—may face distress because their preferred body image of slenderness contrasts with that displayed for males in the popular media of muscularity and large physique. Finally, concerns about being accepted by family and peers may also affect the emotional well-being of sexually active youth who engage in same-sex activity. Our findings also indicated that among males engaging in disordered eating, there was an inverse relationship between number of sex partners and emotional well-being. These findings are consistent with other research among females that has shown that individuals engaging in multiple impulsive behaviors often report greater psychopathology, including anxiety, depression, and anger/hostility (23). Treatment providers working with males with disordered eating may want to pay special attention to the state of emotional well-being among males engaging in same-gender sexual activities or who have had sex with multiple partners.
Of further concern is the poorer family connectedness among those males with disordered eating and weight-control behaviors who also reported same-gender sexual activity or multiple sex partners. Results from other studies indicated that males who report an adverse family background or serious childhood physical abuse show a significantly higher increased risk for developing an eating disorder than males with no physical abuse or a positive family atmosphere (7,40). In addition, gay youth have been reported to be subject to family violence (41). Kinzl and colleagues established a temporal order for the association between family violence and disordered eating by asking 301 males about family background (parental relationship and parent-child relationship) during childhood (7). They found an increased risk for eating disorders in men with strained family relationships. Furthermore, a recent study of 102 patients with eating disorder found that childhood trauma was significantly associated with the presence of multiple impulsive behaviors (42). Consequently, there is evidence to postulate that poor family backgrounds may contribute to disordered eating behaviors.
It was surprising to find that self-esteem was higher among those with a greater number of and/or male sex partners, especially in light of the inverse relationship found between male sex partner and emotional well-being. Although the statistically significant differences were small and potentially not clinically meaningful, we wonder if this association might be explained by the novelty- and sensation-seeking qualities that have been found to be associated with eating disorders, predominantly behaviors more characteristic of bulimia nervosa such as binge-eating and engaging in extreme weight-control behaviors in females (22). Future research, possibly using qualitative interviews or detailed questionnaires to capture more thoroughly the specifics of these factors, is warranted.
Given the increased risk for emotional distress among adolescent males who are sexually active with other males, it is important that opportunities for early intervention be considered. One study reported that 72% of self-identified gay adolescents had talked to a mental healthcare professional about depression, anxiety, or sexual orientation problems (43); yet, the results from a separate study of adolescents, irrespective of sexual orientation, indicated that 44.0% of adolescent boys reported that they would be too embarrassed or uncomfortable talking about sexuality with their healthcare provider (44). Furthermore, in a separate study of youth, only 7% of boys reported that they had discussed sexual orientation with their physician (45). Although these results come from different studies in which differences in the population base and survey questions are evident, we wonder if self-identified gay adolescents are more distressed, thus more likely to seek help from mental health professionals.
These results showing an association between homosexual sexual orientation and lower likelihood to talk about sexuality are very concerning because they suggest a high level of mental health needs and risks, but low likelihood to use available resources to talk about sexuality and sexual orientation. Consequently, it is critical for healthcare providers and school personnel to identify youth who are sexually active with same-sex partners and provide opportunities for discussion. Identification and discussion may be promoted by asking about sexual activity in a manner that connotes acceptance of all sexual orientations. For example, Stewart recommended phrasing questions such as "Do you have romantic feelings about men (boys), women (girls), or both?" and "Are you having or have you had a relationship with men (boys), women (girls), or both?" (46) Given the findings from the current study, in which greater number of same or opposite sex partners was also associated with greater health behavior risks, healthcare providers, school personnel, and other concerned persons should query youths about the number of sex partners. In addition, Andersen and Holman promoted specific treatment considerations for males with disordered eating, including providing same-gender therapists, special groups for some issues of greater sensitivity (e.g., sexuality, body image), and notable differences between females and males with respect to body image and the esthetic ideal (1).
Individuals who acknowledge having sexual activity should be given the opportunity to discuss the nature and quality of these activities. The survey used in the current study did not clarify the quality or consensual nature of the relationship between the study participant and the sex partner. Research has demonstrated that being physically or sexually violated on a date is associated with greater psychopathology, including increased risk for disordered eating behaviors and depression as well as suicidal thoughts and attempts (47,48). Other studies have found that boys with a history of sexual abuse were five times more likely to develop an eating disorder than boys without a history of abuse (49). It is possible that some males in the current study have had sexual intercourse without giving their consent, or may be in an abusive relationship. The quality of the sexual activity among sexually active adolescent males warrants further investigation in research and clinical practice.
Strengths and Limitations
In the current study, the use of a large population-based sample to assess disordered eating behaviors, sexual activity, and psychosocial factors among sexually active adolescent males is a significant strength and allows for generalization of the data to similar samples. The survey includes broad assessment of eating behaviors and psychosocial concerns, thus further enhancing the study’s findings among this nonclinical sample. As the survey assesses adolescent males in a school setting, as opposed to a clinical sample, participant responses are more likely to generalize to the broad population of sexually active males engaging in same-sex activities. Finally, the anonymous self-report survey increases the likelihood of obtaining valid and honest responses about these sensitive, personal issues.
Several limitations warrant consideration when interpreting the current results. Previous reports have sampled individuals who specifically identify themselves as homosexual, whereas the current study did not address self-identified sexual orientation but did query on same-sex behaviors. This categorization difference is a concern as it leaves room for errors, in that adolescents who identify as homosexual may not be sexually active, and thus would be excluded from this study given the current selection criteria, and that some adolescents who have had sex with males may not identify as gay (50). Consequently, although the current study findings are consistent with other studies of homosexual males, extrapolations from the current study to gay males should be used with caution. Future research may choose to use specific objective measures for assessing sexual orientation (51). Furthermore, the current survey did not address specific issues related to sexual activity that may influence the associations between disordered eating and sexual activity, such as if the sexual intercourse was consensual, the frequency of the sexual activity even with the same sex partner, and the nature and duration of the relationship between the study participant and the partner(s). Further research should ask more specific questions, or conduct interviews about self-identified sexual orientation and characteristics of the sex partners to elucidate these findings. In addition, the current survey only asked about disordered eating behaviors. The full spectrum of diagnostic criteria (including behaviors, cognitions, fears, etc.) associated with eating disorders, precipitants to disordered eating, and actual height and weight measurements were not measured; thus, the findings should not be interpreted as being able to reflect risk for full threshold eating disorders. Finally, the cross-sectional nature of the data does not allow for determination of cause and effect; thus, readers should be cautious about directional interpretations, and the historical recall of the number of partners within the last 12 months increases the risk of errors.
Clinical Implications
This study demonstrates the need for professionals working with youth to be aware of the prevalence of disordered eating behaviors among all adolescent males, particularly those who are engaging with multiple sex partners and/or same-sex sexual activity. Of particular concern is that males dually engaging in disordered eating behavior as well as sex with other males may be hesitant to disclose either behavior, owing to associated stigma, and thus may be more difficult to identify without the opportunity for an in-depth discussion. Consequently, school counselors and healthcare professionals should be sensitive to the unique needs and presentations among sexually active males who engage in disordered eating; they should consider offering separate support groups to enhance emotional health and address family connections.
We thank the Minnesota Department of Children, Families, and Learning for their generosity in allowing these analyses and the manuscript.
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Received for publication December 7, 2006; revision received September 26, 2007.
DOI:10.1097/PSY.0b013e318164230c
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