SINGAPORE – Eating disorders have an aesthetic, and it is decidedly female. Waif-thin girls with matchstick legs and thigh gaps on social media sites such as Tumblr. Beautiful dancers, models and actresses splayed on the toilet floor in movies and TV shows, throwing up their dinners. 

But the female face of this condition obscures another vulnerable group: young men. 

Like many of his female counterparts, Brian (not his real name) started feeling the pressure to look a certain way in his early teens. 

“I used to play badminton in primary school, but because I was one of the bigger-sized pupils, I was known for being slow in my movements. I was also dragged off to the TAF club,” says the physiotherapist, now 31, referring to the Trim and Fit programme targeting obesity in schools between 1992 and 2007. 

While he was initially able to laugh it away, the fat shaming affected him in his final year of primary school. 

“I had cousins around my age who got really fit because they started playing water polo. We were quite close and I wanted to be like them. It was also around that time that I was first exposed to fitness-related products, like Men’s Health magazines.” 

So he started skipping meals and went running daily, chalking up as much as 60km in mileage a week.

At first, it felt like his efforts were paying off. Friends marvelled at his weight loss and complimented his new figure. 

“The positive reinforcement became like a motivator. Each time I lost weight, I acquired a new target,” he recalls. 

But his obsession with fitness quickly spiralled out of control. He would skip social gatherings in order to exercise more or to avoid awkward questions about why he was not eating. 

“I didn’t want my friends to see it as a problem. I was embarrassed because skipping meals felt like something only girls did, and I didn’t want them to see me differently.” 

His parents eventually forced him to seek help when he was 13, taking him to doctors, psychologists and dietitians – to no avail. 

Despite his declining health, he had no intention to change. “Getting skinnier meant getting fitter to me, and I felt like everything was going smoothly. Plus, I was happy with my non-existent social life,” he recounts.

For fitness instructor Ryan Thng, 36, anorexia started with his desperation for control. 

The eldest child in a middle-class Christian family of five, he always felt the pressure to uphold the image of a picture-perfect household. 

“I was expected to perform academically and be a role model in church. But I felt constrained by the path that I was expected to follow, and there was always this tension between the ideal I was supposed to live up to and my own wants, which I could not express at the time,” he says. 

Wherever he went, the feeling of displacement persisted. In secondary school, he did not get along with the rest of the boys, who were into sports. He got along better with his female classmates, but still felt like he did not quite fit in.

“I thought that maybe if I looked a little better, people might like me more, and I might be a little happier. Exercising was my only way of asserting control over my life.” 

He started losing weight in Secondary 4 and, by the time he started junior college, he was mainly subsisting on a diet of salads. 

Contrary to his expectations, his mental and physical health continued to deteriorate. 

“I couldn’t stop exercising, but I still was not happy. I was feeling sluggish and could not function in school. I scraped by by memorising things,” says the former Anglo-Chinese Junior College student, who weighed just 40kg by the end of junior college. 

Brian and Mr Thng are not outliers by any means.

A 2021 study published in the International Journal of Eating Disorders screened 797 Singaporean adults aged between 21 and 77. It found that the ratio of men to women who screened positive for an eating disorder was nearly 1:1. 

Despite this parity between the genders, men have traditionally been more reluctant to seek help.

According to a 2014 report in the Asean Journal of Psychiatry, men made up around 8 per cent of the 974 patients who sought treatment at the Eating Disorders Clinic at Singapore General Hospital (SGH) from 2003 to 2012. 

But the tide is starting to turn. SGH says that over the past few years, around 10 per cent of the new patients on its Eating Disorder Programme are male, up from about 8 per cent a decade ago. It sees 140 to 170 new patients each year.

Better Life Psychological Medicine Clinic, a private practice in Novena, has also seen some 10 per cent more male patients as compared with five years ago. It sees around 80 such patients each year.

At The Other Clinic, which provides psychological services in Geylang, the number of male patients has increased twofold from 2021, rising from two to six.

According to Mr Dion Lo, a senior clinical psychologist at Better Life Psychological Medicine Clinic: “The trend seems promising and may be related to increased mental health literacy about eating disorders.”

Social media has also given rise to heightened comparison among men, he notes. And bodybuilding fad diets that encourage men to count their macronutrients and micronutrients have gained popularity in recent years.

Though it was the alarming weight loss of Brian and Mr Thng that alerted their families to their condition, weight loss is not the only indicator of disordered eating in men. 

Dr Ng Kah Wee, senior consultant at SGH’s department of psychiatry, says not all male patients are driven by a desire for thinness, unlike their female counterparts. Many of them may hanker after a certain body type or simply fear being overweight.

For example, the male patients at Better Life Psychological Medicine Clinic do not usually display severe weight loss. Rather, they are more susceptible to bulimia nervosa or binge-eating disorders. 

Dr Kim Lian Rolles-Abraham, the clinic’s principal clinical psychologist, says this might be because the idealised masculine body does not mirror the stick-thin physique some women strive for. 

Often, as was the case for Brian and Mr Thng, it takes a family member stepping in to force the individual to seek help, although the lack of distinct physical attributes can make it difficult for loved ones to spot the warning signs.

“Because the severe weight problems are usually not evident, it may be hard to justify at times if a patient is simply very serious about his hobby, like bodybuilding, or if he is being overly obsessive about it,” says Mr Lo. 

“We often have to closely monitor the intensity of their behaviours – such as the frequency and duration of their activities – as well as rely on regular feedback from loved ones to determine the severity of the problem.” 

Moreover, because of the “feminisation” of eating disorders, some men may take longer to seek treatment, according to the 2014 study by the SGH team.

It found that on average, male patients in Singapore report 36 months of untreated illness, longer than female patients, who take around 26 months to seek help.  

Ms Annelise Lai, a clinical psychologist at The Other Clinic, observes: “Caring for our appearance, body and weight is commonly recognised as a feminine problem. Men often delay seeking help because of the shame and stigma they experience when they care so much about their weight or body shape.”

Mr Thng recalls: “Even for me to admit to myself that I had a mental problem was hard. Throughout my first year in treatment, I just kept viewing the issue as a matter of gastrointestinal distress from my diet.” 

Mr Lo adds that because men typically endure their condition for a longer period of time, their unhealthy habits become more deeply entrenched and, hence, harder to break.  

And seeking treatment is only the first step. 

“Male patients may not tell you the extent of their struggles, due to shame and fear of stigma.

“For the same reasons, they may not be receptive to the involvement of a loved one or caregiver in their recovery process,” says Dr Rolles-Abraham. 

Indeed, Mr Thng and the seven other men he met over the course of his treatment at SGH initially found it difficult to open up during their psychotherapy group sessions. 

“The guys I knew were unable to articulate their emotional needs or express their strong emotions well. So we had a lot of trouble sharing at first,” he says.

“But as I got to know the group and the therapist better, it became easier for me,” he adds. 

Ultimately, Brian says, the desire to get better has to come from the individual himself. The professional help he received from when he was aged 13 to 18 did not always work.

“I sometimes felt like it was a waste of time. I could click with some therapists, but I got the sense that others were just there to do their job. So I didn’t feel like opening up,” he says.

It was only when he started getting into longer-term relationships in his early 20s that he was finally convinced of the need to change his ways. That was also when he started to pick up running seriously. 

“I had always assumed that I wouldn’t be as fit or as fast if I ate proper meals, but when I started eating more at around age 22 to match my girlfriend, I discovered that I actually had more energy to run better,” he says. 

While there is no sure way of preventing eating disorders, Dr Ng says developing a wide range of healthy coping mechanisms can dissuade one from falling back on over-exercising in times of stress. 

It also helps to set your priorities straight. Nowadays, Brian runs even longer distances daily – totalling up to 100km a week – but never on an empty stomach, and rarely at the expense of family time. 

“I’m still making up for the years I lost to my eating disorder.”