EMPIRICAL ARTICLE
Young Peoples’ Stigmatizing Attitudes and Beliefs about Anorexia Nervosa and Muscle Dysmorphia Scott Griffiths, BPsych (Hons)1* Jonathan M. Mond, PhD2 Stuart B. Murray, PhD3 Stephen Touyz, PhD1
ABSTRACT Objective: The nature and extent of stigma toward individuals with anorexia nervosa and muscle dysmorphia remains underexplored. This study investigated attitudes and beliefs likely to be conducive to stigmatization of individuals with these conditions. Method: Male and female undergraduate students (n 5 361) read one of four vignettes describing a fictional male or female character with anorexia nervosa or muscle dysmorphia, after which they responded to a series of questions addressing potentially stigmatizing attitudes and beliefs toward each character. Results: Characters with anorexia nervosa were more stigmatized than characters with muscle dysmorphia, female characters were more stigmatized than male characters, and male participants were more stigmatizing than female participants. A large effect of character diagnosis on masculinity was observed, such
Introduction Comparatively little stigma research has been conducted on eating disorders and even less research has investigated sex differences in stigma toward sufferers. Accumulating evidence suggests that men with eating disorders feel additional shame and guilt for having ostensibly “female problems” and that these beliefs impede treatment-seeking.1 However, whether the public views male sufferers of anorexia nervosa as more feminine or less masculine is unclear. If anorexia nervosa is viewed as a “female problem”, then muscle dysmorphia can be viewed as Accepted 11 October 2013 *Correspondence to: S. Griffiths; School of Psychology, University of Sydney, New South Wales 2006, Australia. E-mail: [email protected] 1 School of Psychology, University of Sydney, New South Wales, 2006, Australia 2 School of Psychology, The Australian National University, Canberra, Australian Capital Territory, 0200, Australia 3 The Redleaf Practice, Wahroonga, New South Wales, 2076, Australia Published online 12 November 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22220 C 2013 Wiley Periodicals, Inc. V
International Journal of Eating Disorders 47:2 189–195 2014
that characters with anorexia nervosa were perceived as less masculine than characters with muscle dysmorphia, and this effect was more pronounced among male participants. However, no significant corresponding effects were observed for femininity. Discussion: Females with anorexia nervosa may be particularly susceptible to stigmatization, especially by males. Anorexia nervosa and muscle dysmorphia are perceived as “female” and “male” disorders respectively, in line with societal gender role expectations, and this stigmatization is tied more strongly to perceptions of sufferers’ masculinity than C 2013 Wiley Periodicals, Inc. femininity. V Keywords: stigma; anorexia nervosa; muscle dysmorphia (Int J Eat Disord 2014; 47:189–195)
the quintessential “male problem.” Muscle dysmorphia is a psychological condition mostly affecting men in which sufferers believe themselves to be insufficiently muscular, leading them to engage in disordered eating and exercising behaviours to try and increase their muscularity.2 Debate surrounding the classification of muscle dysmorphia is ongoing. Although currently classified in the DSM 5 as a subtype of body dysmorphic disorder, a growing number of researchers argue that muscle dysmorphia belongs to the eating disorder spectrum and is representative of the “male experience” of eating and body image psychopathology.3 Stigma toward muscle dysmorphia and anorexia nervosa may overlap considerably. Research indicates that people believe anorexia nervosa to be under the personal control of those who suffer from it, that sufferers are attention-seekers who could pull themselves together, and that sufferers are personally responsible for their illness and therefore have only themselves to blame.4–7 Muscle dysmorphia may attract these same beliefs, insofar as sufferers appear outwardly healthy, are obsessional about their body image and body change behaviours, may seek frequent reassurance from 189
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others about their muscularity, and are typically successful in changing their weight and shape.8 To date, however, no research has examined stigma in muscle dysmorphia. Research examining whether and how attitudes and beliefs depend on the sex of the sufferer is also limited. Wingfield et al.9 showed that men with eating disorders were considered more likely to recover than females. However, this study did not examine stigmatization related to gender role stereotypes, such as the perceived masculinity and femininity of male versus female sufferers. Male sufferers of anorexia nervosa and female sufferers of muscle dysmorphia may be subject to harsher stigmatization because they are in conflict with societal gender role expectations. In support of this conjecture, men with eating disorders report additional stigmatization for having a “female problem”1 and gender atypical youth are frequently stigmatized by their peers.10,11 Finally, few studies have examined sex differences among those who stigmatize individuals with eating disorders. Wingfield et al.9 found mixed differences between male and female participants in their beliefs toward characters with eating disorders, with female participants rating the characters as more likeable, but also more self-destructive and less likely to recover than male participants. Findings from one other recent study suggested that young males perceive eating disorders to be “less serious” than young females.12 No research has examined sex differences in beliefs about muscle dysmorphia. The aim of this study was to examine young people’s attitudes and beliefs toward individuals with anorexia nervosa and muscle dysmorphia. The study focussed on attitudes and beliefs likely to be conducive to stigma and discrimination, and additionally considered the effects of both sufferer and participant sex on these attitudes and beliefs. Given the paucity of evidence regarding stigma toward muscle dysmorphia and sex differences in stigma toward anorexia nervosa, no specific hypotheses were formulated.
Method Participants Participants were 361 first-year psychology undergraduates who received course credit for their participation. The study was approved by the Human Research and Ethics Committee at the University of Sydney. Data Exclusion. Two valid-responding checks were included in the study. The first check (“For validity pur-
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poses, please select “Agree” as your answer to this question”) was embedded in the questionnaires, and the second check asked participants at the end of the study to name the character described in their vignette. The first and second validity checks were correctly answered by 90.6 and 89.2% of participants, respectively. Eight participants who failed both checks had their data excluded together with 10 participants who provided an opposite sex name for the second check question. One transgender participant was also excluded. Participant Characteristics. The postexclusion sample size was 343 and included 113 males and 230 females ranging in age from 16 to 40 years (M 5 19.24, SD 5 2.9). Participants were predominantly Australian (60.9%), followed by North-East Asian (11.1%), European (9.4%), and Southern and Central Asian (6.1%), with 12.5% indicating other nationalities. The BMI of the sample ranged from 15.52 to 47.18 with a mean of 22.6 (SD 5 4.23). Materials and Measures Vignettes. Modified versions of the vignettes used by Mond et al.6,13 described a fictional male (“Michael”) or female character (“Kelly”) who was experiencing clinically significant symptoms of either anorexia nervosa or muscle dysmorphia (see Appendix A). The vignettes did not explicitly state diagnoses, but they did describe the central features of anorexia nervosa or muscle dysmorphia. Assessment of Stigmatizing Attitudes and Beliefs. Potentially stigmatizing attitudes and beliefs were assessed using items developed by Crisp et al.,5 Mond et al.6, Roehrig and McLean,7 and Stewart et al.14 (see Table 1). Participants rated their level of agreement using a 5-point Likert scale (1 5 strongly agree and 5 5 strongly disagree). Several items were added because they appeared relevant to sex differences between anorexia nervosa and muscle dysmorphia, or because they were anecdotally associated with stereotypes about muscle dysmorphia. Design and Procedure The study used a 2 3 2 3 2 between-subjects design. The three independent variables were character diagnosis (anorexia nervosa or muscle dysmorphia), character sex (male or female), and participant sex (male or female). The dependent variables were items assessing potentially stigmatizing attitudes and beliefs toward the character. Microsoft Excel was used to randomly allocate participants to one of four groups. Each group of participants was emailed a link to an online survey that contained the vignette corresponding to their group. Participants were instructed to carefully read the vignette and were then International Journal of Eating Disorders 47:2 189–195 2014
BELIEFS ABOUT ANOREXIA AND MUSCLE DYSMORPHIA TABLE 1. Descriptive statistics for each item assessing potentially stigmatizing attitudes and beliefs toward the characters as a function of character diagnosis, character sex, and participant sex Character Diagnosis Anorexia Nervosa Item 1. They are feminine 2. They are masculine 3. They are weird 4. They are intelligent 5. They are a danger to others 6. They are a narcissist 7. They are self-destructive 8. They have self-control 9. They are likeable 10. They are heterosexual 11. They are similar to me 12. They will recover easily 13. Others willing to be friends 14. Strain on your friendship 15. You watch or monitor 16. Others watch or monitor 17. Likelihood of talking about their problem 18. Uncomfortable talking to them 19. Uncomfortable in social situations 20. Cautious not to upset 21. Responsible for their condition 22. Able to pull self together 23. Less competent 24. Using disorder to get attention 25. Physically fragile 26. Psychologically fragile 27. Discriminated against
Character Sex
Muscle Dysmorphia
Male
Participant Sex
Female
Male
Female
M
SD
M
SD
M
SD
M
SD
M
SD
M
SD
2.63 2.54 2.10 2.87 2.01 2.73 3.49 3.12 3.21 3.09 2.48 2.51 3.07 2.42 3.80 3.35 3.45 2.45 1.99 3.14 2.50 2.43 2.44 1.88 2.88 3.57 2.73
1.04 0.77 0.88 0.63 0.90 0.83 0.92 1.03 0.69 0.55 1.09 0.87 0.71 0.94 0.96 0.84 1.03 1.04 1.02 1.04 0.99 1.03 0.68 0.93 1.05 0.98 0.96
2.43 3.34 2.26 3.14 1.87 2.78 3.09 3.38 3.33 3.06 2.40 2.83 3.05 2.13 3.14 2.79 2.98 2.43 1.78 2.75 2.42 2.53 2.69 2.01 2.08 3.32 2.61
0.94 0.82 0.88 0.50 0.75 0.85 0.87 0.98 0.63 0.38 1.01 0.72 0.71 0.98 1.13 0.97 1.06 1.04 1.04 1.14 0.94 0.94 0.69 0.91 0.97 0.94 0.97
1.98 3.18 2.12 3.06 1.88 2.85 3.25 3.24 3.23 3.06 2.49 2.79 3.14 2.23 3.35 2.91 3.18 2.29 1.88 2.85 2.42 2.51 2.53 1.98 2.37 3.32 2.52
0.79 0.81 0.82 0.54 0.80 0.82 0.90 1.03 0.65 0.49 1.02 0.86 0.70 0.93 1.16 0.96 1.08 1.02 1.08 1.14 0.97 1.04 0.69 0.97 0.98 1.04 0.96
3.08 2.72 2.23 2.95 1.99 2.66 3.32 3.27 3.31 3.08 2.40 2.56 2.98 2.32 3.58 3.22 3.24 2.58 1.90 3.03 2.50 2.45 2.62 1.91 2.58 3.56 2.81
0.87 0.91 0.94 0.62 0.85 0.85 0.94 1.00 0.67 0.45 1.08 0.75 0.71 1.01 1.03 0.92 1.06 1.04 0.99 1.07 0.95 0.93 0.70 0.87 1.19 0.87 0.95
2.53 3.06 2.46 2.96 1.88 2.97 3.20 3.23 3.13 3.15 2.46 2.80 2.93 2.18 2.96 2.79 2.92 2.48 1.79 2.73 2.60 2.65 2.63 2.14 2.47 3.29 2.62
0.96 0.87 0.87 0.55 0.77 0.90 0.93 1.00 0.59 0.49 1.02 0.83 0.72 0.95 1.08 0.94 1.16 1.02 1.02 1.09 0.93 1.01 0.72 1.06 1.12 0.98 1.00
2.52 2.90 2.04 3.03 1.97 2.65 3.33 3.27 3.33 3.03 2.44 2.61 3.12 2.33 3.71 3.21 3.36 2.42 1.93 3.05 2.40 2.40 2.54 1.86 2.47 3.52 2.69
1.01 0.90 0.86 0.60 0.86 0.79 0.91 1.02 0.68 0.46 1.06 0.80 0.70 0.98 1.02 0.93 1.00 1.05 1.04 1.09 0.97 0.96 0.68 0.83 1.08 0.96 0.95
Bold indicates statistically significant main effects after using Hochberg’s step-up procedure to control the family-wise error rate at 0.05.
asked questions about the character described in the vignette. Statistical Analyses. A series of univariate analysis of variances (ANOVAs) were conducted with character diagnosis, character sex and participant sex entered as independent variables, and the stigma items entered as dependant variables. The family-wise error rate was controlled at 0.05 using Hochberg’s step-up procedure.15 Effect sizes are given as partial-eta squared g2 and were interpreted using Cohen’s (1988) guidelines: small (g2 5 0.01), medium (g2 5 0.06), and large (g2 5 0.14).
Results Table 1 shows descriptive statistics for participants’ responses to the stigma items averaged across each level of each independent variable. The ANOVAs showed significant main effects for each independent variable, and significant interactions between character diagnosis and character sex, and between character diagnosis and participant sex. There were no significant three-way interactions, and no significant interactions between character sex and participant sex. Only significant findings were interpreted. International Journal of Eating Disorders 47:2 189–195 2014
Effects of Character Diagnosis
As shown in Figure 1, there was a large effect of character diagnosis on the perceived masculinity of the character, such that characters with muscle dysmorphia were rated as more masculine than characters with anorexia nervosa, F(1, 334) 5 101.54, p < 0.001, g2 5 0.23. Furthermore, the effect of character diagnosis on perceived masculinity was more pronounced for male participants than for female participants, F(1, 334) 5 8.43, p 5 0.004, g2 5 0.03. Characters with anorexia nervosa were rated as less intelligent, F(1, 334) 5 13.36, p < 0.001, g2 5 0.04, less competent than their peers, F(1, 334) 5 9.68, p 5 0.002, g2 5 0.03, and more selfdestructive, F(1, 334) 5 12.78, p < 0.001, g2 5 0.04, than characters with muscle dysmorphia. Participants further believed that characters with anorexia nervosa would place greater strain on their friendship, F(1, 334) 5 9.29, p 5 0.002, g2 5 0.03, were more likely to be watched or monitored by the participant, F(1, 334) 5 38.63, p < 0.001, g2 5 0.10, and by others, F(1, 334) 5 40.73, p < 0.001, g2 5 0.11, and were less likely to recover easily than characters with muscle dysmorphia, F(1, 334) 5 191
GRIFFITHS ET AL. FIGURE 1 Mean perceived masculinity as a function of character diagnosis (anorexia nervosa or muscle dysmorphia) and participant sex (male or female). Perceived masculinity was significantly greater for characters with muscle dysmorphia compared with characters with anorexia nervosa, and this effect was significantly more pronounced among male participants. Errors bars represent 95% confidence intervals.
7.88, p 5 0.005, g2 5 0.02, and less likely to recover easily than male characters, F(1, 334) 5 7.33, p 5 0.007, g2 5 0.02. Interestingly, male characters were rated as less likely to be discriminated against in the community, F(1, 334) 5 12.93, p < 0.001, g2 5 0.04, and this effect was stronger among female participants than male participants, F(1, 334) 5 8.16, p 5 0.005, g2 5 0.02. Effects of Participant Sex
Male participants rated characters as more weird, F(1, 334) 5 18.55, p < 0.001, g2 5 0.05, more narcissistic, F(1, 334) 5 11.72, p 5 0.001, g2 5 0.03, and more likely to be trying to get attention for themselves, F(1, 334) 5 7.51, p 5 0.006, g2 5 0.02, compared with female participants. In addition, male participants indicated that they were less likely to personally feel the need to watch or monitor the characters, F(1, 334) 5 42.17, p < 0.001, g2 5 0.11, believed it is less likely that others would feel the need to watch or monitor the characters, F(1, 334) 5 16.66, p < 0.001, g2 5 0.05, and were less likely to talk to the character about their problem, F(1, 334) 5 13.66, p < 0.001, g2 5 0.04, than female participants. 9.90, p 5 0.002, g2 5 0.03. Participants also reported that they would need to be more cautious not to upset characters with anorexia nervosa compared to characters with muscle dysmorphia F(1, 334) 5 14.97, p < 0.001, g2 5 0.04. Finally, participants were more likely to talk to characters with anorexia nervosa about their problem than characters with muscle dysmorphia F(1, 334) 5 20.77, p < 0.001, g2 5 0.06, and this effect was more pronounced when the character was male rather than female, F(1, 334) 5 7.47, p 5 0.007, g2 5 0.02. Characters with anorexia nervosa were also perceived as more physically fragile than characters with muscle dysmorphia, F(1, 334) 5 51.09, p < 0.001, g2 5 0.13, and this effect was more pronounced for female characters, F(1, 334) 5 10.48, p 5 0.001, g2 5 0.03. Effects of Character Sex
As expected, male characters were rated as more masculine, F(1, 334) 5 23.70, p < 0.001, g2 5 0.07, and less feminine than female characters, F(1, 334) 5 121.61, p < 0.001, g2 5 0.27. Participants believed that female characters were more likely to be watched or monitored by others, F(1, 334) 5 10.79, p 5 0.001, g2 5 0.03, more uncomfortable to talk to about their problem, F(1, 334) 5 9.45, p 5 0.002, g2 5 0.03, more psychologically fragile, F(1, 334) 5 192
Discussion This study aimed to investigate young peoples’ stigmatizing attitudes and beliefs about men and women with anorexia nervosa and muscle dysmorphia. Overall, characters with anorexia nervosa were more stigmatized than characters with muscle dysmorphia. The former were rated as less intelligent, more self-destructive, less competent than their peers, more likely to strain the participants’ friendship, more likely to prompt cautious behaviour from the participant, more likely to be watched or monitored by the participant and by others, and less likely to recover easily compared to characters with muscle dysmorphia. In addition, participants were more likely to talk to characters with anorexia nervosa about the problem, especially when the character was male, and characters with anorexia nervosa were rated as more physically fragile, especially when the character was female. Thus, it seems that anorexia nervosa may engender harsher stigmatization than muscle dysmorphia. Alternatively, muscle dysmorphia might have been perceived more favourably than anorexia nervosa because young people may be relatively less familiar and/or knowledgeable about muscle dysmorphia, making them less likely to associate International Journal of Eating Disorders 47:2 189–195 2014
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symptoms of muscle dysmorphia with mental illness. Given that mental illnesses in general attract stigma,5 this could have translated into lesser stigmatization of muscle dysmorphia. Nevertheless, both explanations have clinical implications. If anorexia nervosa is indeed more stigmatized, this would probably impede treatment seeking. Alternatively, if people with muscle dysmorphia are perceived as having “less” of a mental illness than anorexia nervosa, sufferers may internalise that they do not have a “real disorder”, again impeding treatment seeking. However, differences in participants’ level of knowledge about the diagnoses are unlikely to explain the strong evidence found in this study that anorexia nervosa and muscle dysmorphia are perceived as a “female problem” and “male problem,” respectively. The large effect of character diagnosis on the perceived masculinity of the character was such that characters with anorexia nervosa were perceived as considerably less masculine than characters with muscle dysmorphia; an effect that was stronger for male participants. Interestingly, however, there was no significant effect of character diagnosis on perceived femininity. It seems that the extent to which anorexia nervosa and muscle dysmorphia are gender stereotyped may be much more strongly linked to how masculine each condition is perceived, rather than how feminine. Indeed, the effect size of character diagnosis on masculinity was over three times larger than the effect size for character sex, indicating that the contribution of one’s biological status as a male or female is overshadowed by one’s thinness- or muscularity-oriented psychopathology in terms of how masculine oneself is perceived. Interestingly, research has shown that conformity to traditional masculine norms is higher in men with muscle dysmorphia than in men with anorexia nervosa,16 and that conformity to traditional norms is more generally associated with muscle dissatisfaction among males.17 However, men with anorexia nervosa and healthy control men report equal conformity to masculine norms.16 Overall, female characters were more stigmatized than male characters. Female characters were rated as more psychologically fragile, more uncomfortable to talk to, more likely be watched or monitored by others, and less likely to recover easily, compared with male characters. Some of these findings fall in line with gender stereotypes, namely that females are more psychologically fragile. Others, such as the belief that females would be more uncomfortable to talk to, point to potentially damaging elements of interpersonal stigma that International Journal of Eating Disorders 47:2 189–195 2014
may be exacerbated among females with eating disorders. Interestingly, male characters were believed to be less likely to face discrimination in the community than female characters, contrary to most assumptions, and this effect was stronger among female participants. Male participants stigmatized characters more than female participants. Male participants believed characters were weirder, more narcissistic, more likely to be trying to get attention for themselves, less likely to be watched or monitored by the participant and by others, and less likely to be talked to by the participant about their problems. These findings are inconsistent with previous research by Wingfield et al.9 who found that male and female participants were mostly equivalent in their beliefs toward characters with eating disorders. However, the findings are consistent with those of Mond and Arrighi,12 who found that young males considered anorexia nervosa to be a less serious condition than young females. The current findings extend the sex difference in perceived severity of eating disorders to also include muscle dysmorphia. Several limitations of this study are noted. First, participants were undergraduate psychology students rather than a general population sample of young people. Psychology students may be more knowledgeable of anorexia nervosa and muscle dysmorphia, and perhaps, less likely to have—or be willing to report—stigmatizing attitudes and beliefs, limiting the generalizability of the current findings. Second, the vignettes were not pilot tested by experts in the field to determine whether they were representative of the respective disorders they were aimed at describing. However, this limitation is qualified by the lack of consensus surrounding the diagnostic criteria for muscle dysmorphia, and by the fact that the anorexia nervosa vignette used in the current study was closely based on anorexia nervosa vignettes used in previous stigma research. Third, the contribution of participants’ level of knowledge about muscle dysmorphia and anorexia nervosa to stigmatization was not investigated.
Conclusion We investigated young peoples’ beliefs and attitudes toward men and women with anorexia nervosa and muscle dysmorphia using a vignette paradigm. Characters with anorexia nervosa were more stigmatized than characters with muscle dysmorphia, female characters were more stigmatized than male characters, and male participants were 193
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more stigmatizing than female participants. There was strong evidence to suggest that anorexia nervosa and muscle dysmorphia are stigmatized as a “female” and “male” condition in line with societal gender role expectations, and this stigmatization is tied more strongly to perceptions of sufferers’ masculinity than to femininity.
References 1. Robinson KJ, Mountford VA, Sperlinger DJ. Being men with eating disorders: Perspectives of male eating disorder service-users. J Health Psychol 2013;18: 176–186. 2. Pope HG, Gruber A, Choi P, Olivardia R. Muscle dysmorphia: An underrecognized form of body dysmorphic disorder. Psychosomatics 1997;38:548–557. 3. Murray SB, Rieger E, Touyz SW, de la Garza Garcıa Y. Muscle dysmorphia and the DSM-V conundrum: Where does it belong? A review paper. Int J Eat Disorder 2010;43:483–491. 4. Crisafulli MA, Holle Von A, Bulik CM. Attitudes towards anorexia nervosa: The impact of framing on blame and stigma. Int J Eat Disorder 2008;41: 333–339. 5. Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of people with mental illnesses. Brit J Psychiat 2000;177:4–7. 6. Mond JM, Robertson-Smith G, Vetere A. Stigma and eating disorders: Is there evidence of negative attitudes towards anorexia nervosa among women in the community? J Ment Health 2006;15:519–532. 7. Roehrig JP, McLean CP. A comparison of stigma toward eating disorders versus depression. Int J Eat Disorder 2010;43:671–674. 8. Olivardia R, Pope H, Hudson J. Muscle dysmorphia in male weightlifters: A case-control study. Am J Psychiat 2000;157:1291–1296. 9. Wingfield N, Kelly N, Serdar K, Shivy VA, Mazzeo SE. College students’ perceptions of individuals with anorexia and bulimia nervosa. Int J Eat Disorder 2011;44:369–375. 10. Haldeman D. Gender atypical youth: Clinical and social issues. School Psychol Rev 2000;29:192–200. 11. Lee EAE, Troop-Gordon W. Peer processes and gender role development: Changes in gender atypicality related to negative peer treatment and children’s friendships. Sex Roles 2011;64:90–102. 12. Mond JM, Arrighi A. Gender differences in perceptions of the severity and prevalence of eating disorders. Early Interv Psychiatry 2011;5:41–49. 13. Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJV. Beliefs of women concerning the severity and prevalence of bulimia nervosa. Soc Psych Psych Epid 2004;39:299–304. 14. Stewart M, Keel PK, Schiavo RS. Stigmatisation of anorexia nervosa. Int J Eat Disorder 2006;39:320–325. 15. Hochberg Y. A sharper Bonferroni procedure for multiple tests of significance. Biometrika 1988;75:800–802. 16. Murray SB, Rieger E, Karlov L, Touyz SW. Masculinity and femininty in the divergence of male body image concerns. J Eat Disorder 2013;1:11. 17. Blashill A. Gender roles, eating pathology, and body dissatisfaction in men: A meta-analysis. Body Image 2011;8:1–11.
Appendix A : Vignette – Female with Anorexia Nervosa Meet Kelly. Kelly is a 19-year-old college student. Although mildly overweight as an adolescent, Kelly’s current weight is well below the normal range for her age and height. However, she thinks that she is overweight. She recently joined a fitness program at the gym and started running daily. 194
Through this effort, she has begun to lose weight. Kelly has also begun to “diet”, avoiding all fatty foods, restricting her food intake by skipping meals, and eating small set amounts of “healthy foods” each day, mainly fruit and vegetables and bread or rice. On occasions, Kelly finds it difficult to control her eating but then she redoubles her efforts to overcome her temptation, eating even less than she usually does and exercising even more. In addition, she has developed an intense fear of gaining any weight.
Vignette – Male with Anorexia Nervosa Meet Michael. Michael is a 19-year-old college student. Although mildly overweight as an adolescent, Michaels’s current weight is well below the normal range for his age and height. However, he thinks that he is overweight. He recently joined a fitness program at the gym and started running daily. Through this effort, he has begun to lose weight. Michael has also begun to “diet”, avoiding all fatty foods, restricting his food intake by skipping meals, and eating small set amounts of “healthy foods” each day, mainly fruit and vegetables and bread or rice. On occasions, Michael finds it difficult to control his eating but then he redoubles his efforts to overcome his temptation, eating even less than he usually does and exercising even more. In addition, he has developed an intense fear of gaining any weight.
Vignette – Female with Muscle Dysmorphia Meet Kelly. Kelly is a 19-year-old college student. Although mildly underweight as an adolescent, Kelly’s current weight is well above the average range for her age and height. Her body is muscular with little body fat. However, she thinks that she is underweight and “scrawny”. She recently began extra weightlifting sessions at the gym and started running daily. Through this effort, she has begun to gain more muscle and muscle definition. Kelly has also begun to “diet”, avoiding all fatty foods and eating large amounts of “healthy foods” each day. On occasions, Kelly finds it difficult to control her eating and workouts, but then she redoubles her efforts to overcome her temptations, adhering strictly to her diet and exercising even more. In addition, she has developed an intense fear of losing her muscle mass.
Vignette – Male with Muscle Dysmorphia Meet Michael. Michael is a 19-year-old college student. Although mildly underweight as an International Journal of Eating Disorders 47:2 189–195 2014
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adolescent, Michael’s current weight is well above the average range for his age and height. His body is muscular with little body fat. However, he thinks that he is underweight and “scrawny”. He recently began extra weightlifting sessions at the gym and started running daily. Through this effort, he has begun to gain more muscle and muscle definition. Michael has also
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begun to “diet”, avoiding all fatty foods and eating large amounts of “healthy foods” each day. On occasions, Michael finds it difficult to control his eating and workouts, but then he redoubles his efforts to overcome his temptations, adhering strictly to his diet and exercising even more. In addition, he has developed an intense fear of losing his muscle mass.
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Young Peoples’ Stigmatizing Attitudes and Beliefs about Anorexia Nervosa and Muscle Dysmorphia Scott Griffiths, BPsych (Hons)1* Jonathan M. Mond, PhD2 Stuart B. Murray, PhD3 Stephen Touyz, PhD1
ABSTRACT Objective: The nature and extent of stigma toward individuals with anorexia nervosa and muscle dysmorphia remains underexplored. This study investigated attitudes and beliefs likely to be conducive to stigmatization of individuals with these conditions. Method: Male and female undergraduate students (n 5 361) read one of four vignettes describing a fictional male or female character with anorexia nervosa or muscle dysmorphia, after which they responded to a series of questions addressing potentially stigmatizing attitudes and beliefs toward each character. Results: Characters with anorexia nervosa were more stigmatized than characters with muscle dysmorphia, female characters were more stigmatized than male characters, and male participants were more stigmatizing than female participants. A large effect of character diagnosis on masculinity was observed, such
Introduction Comparatively little stigma research has been conducted on eating disorders and even less research has investigated sex differences in stigma toward sufferers. Accumulating evidence suggests that men with eating disorders feel additional shame and guilt for having ostensibly “female problems” and that these beliefs impede treatment-seeking.1 However, whether the public views male sufferers of anorexia nervosa as more feminine or less masculine is unclear. If anorexia nervosa is viewed as a “female problem”, then muscle dysmorphia can be viewed as Accepted 11 October 2013 *Correspondence to: S. Griffiths; School of Psychology, University of Sydney, New South Wales 2006, Australia. E-mail: [email protected] 1 School of Psychology, University of Sydney, New South Wales, 2006, Australia 2 School of Psychology, The Australian National University, Canberra, Australian Capital Territory, 0200, Australia 3 The Redleaf Practice, Wahroonga, New South Wales, 2076, Australia Published online 12 November 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22220 C 2013 Wiley Periodicals, Inc. V
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that characters with anorexia nervosa were perceived as less masculine than characters with muscle dysmorphia, and this effect was more pronounced among male participants. However, no significant corresponding effects were observed for femininity. Discussion: Females with anorexia nervosa may be particularly susceptible to stigmatization, especially by males. Anorexia nervosa and muscle dysmorphia are perceived as “female” and “male” disorders respectively, in line with societal gender role expectations, and this stigmatization is tied more strongly to perceptions of sufferers’ masculinity than C 2013 Wiley Periodicals, Inc. femininity. V Keywords: stigma; anorexia nervosa; muscle dysmorphia (Int J Eat Disord 2014; 47:189–195)
the quintessential “male problem.” Muscle dysmorphia is a psychological condition mostly affecting men in which sufferers believe themselves to be insufficiently muscular, leading them to engage in disordered eating and exercising behaviours to try and increase their muscularity.2 Debate surrounding the classification of muscle dysmorphia is ongoing. Although currently classified in the DSM 5 as a subtype of body dysmorphic disorder, a growing number of researchers argue that muscle dysmorphia belongs to the eating disorder spectrum and is representative of the “male experience” of eating and body image psychopathology.3 Stigma toward muscle dysmorphia and anorexia nervosa may overlap considerably. Research indicates that people believe anorexia nervosa to be under the personal control of those who suffer from it, that sufferers are attention-seekers who could pull themselves together, and that sufferers are personally responsible for their illness and therefore have only themselves to blame.4–7 Muscle dysmorphia may attract these same beliefs, insofar as sufferers appear outwardly healthy, are obsessional about their body image and body change behaviours, may seek frequent reassurance from 189
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others about their muscularity, and are typically successful in changing their weight and shape.8 To date, however, no research has examined stigma in muscle dysmorphia. Research examining whether and how attitudes and beliefs depend on the sex of the sufferer is also limited. Wingfield et al.9 showed that men with eating disorders were considered more likely to recover than females. However, this study did not examine stigmatization related to gender role stereotypes, such as the perceived masculinity and femininity of male versus female sufferers. Male sufferers of anorexia nervosa and female sufferers of muscle dysmorphia may be subject to harsher stigmatization because they are in conflict with societal gender role expectations. In support of this conjecture, men with eating disorders report additional stigmatization for having a “female problem”1 and gender atypical youth are frequently stigmatized by their peers.10,11 Finally, few studies have examined sex differences among those who stigmatize individuals with eating disorders. Wingfield et al.9 found mixed differences between male and female participants in their beliefs toward characters with eating disorders, with female participants rating the characters as more likeable, but also more self-destructive and less likely to recover than male participants. Findings from one other recent study suggested that young males perceive eating disorders to be “less serious” than young females.12 No research has examined sex differences in beliefs about muscle dysmorphia. The aim of this study was to examine young people’s attitudes and beliefs toward individuals with anorexia nervosa and muscle dysmorphia. The study focussed on attitudes and beliefs likely to be conducive to stigma and discrimination, and additionally considered the effects of both sufferer and participant sex on these attitudes and beliefs. Given the paucity of evidence regarding stigma toward muscle dysmorphia and sex differences in stigma toward anorexia nervosa, no specific hypotheses were formulated.
Method Participants Participants were 361 first-year psychology undergraduates who received course credit for their participation. The study was approved by the Human Research and Ethics Committee at the University of Sydney. Data Exclusion. Two valid-responding checks were included in the study. The first check (“For validity pur-
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poses, please select “Agree” as your answer to this question”) was embedded in the questionnaires, and the second check asked participants at the end of the study to name the character described in their vignette. The first and second validity checks were correctly answered by 90.6 and 89.2% of participants, respectively. Eight participants who failed both checks had their data excluded together with 10 participants who provided an opposite sex name for the second check question. One transgender participant was also excluded. Participant Characteristics. The postexclusion sample size was 343 and included 113 males and 230 females ranging in age from 16 to 40 years (M 5 19.24, SD 5 2.9). Participants were predominantly Australian (60.9%), followed by North-East Asian (11.1%), European (9.4%), and Southern and Central Asian (6.1%), with 12.5% indicating other nationalities. The BMI of the sample ranged from 15.52 to 47.18 with a mean of 22.6 (SD 5 4.23). Materials and Measures Vignettes. Modified versions of the vignettes used by Mond et al.6,13 described a fictional male (“Michael”) or female character (“Kelly”) who was experiencing clinically significant symptoms of either anorexia nervosa or muscle dysmorphia (see Appendix A). The vignettes did not explicitly state diagnoses, but they did describe the central features of anorexia nervosa or muscle dysmorphia. Assessment of Stigmatizing Attitudes and Beliefs. Potentially stigmatizing attitudes and beliefs were assessed using items developed by Crisp et al.,5 Mond et al.6, Roehrig and McLean,7 and Stewart et al.14 (see Table 1). Participants rated their level of agreement using a 5-point Likert scale (1 5 strongly agree and 5 5 strongly disagree). Several items were added because they appeared relevant to sex differences between anorexia nervosa and muscle dysmorphia, or because they were anecdotally associated with stereotypes about muscle dysmorphia. Design and Procedure The study used a 2 3 2 3 2 between-subjects design. The three independent variables were character diagnosis (anorexia nervosa or muscle dysmorphia), character sex (male or female), and participant sex (male or female). The dependent variables were items assessing potentially stigmatizing attitudes and beliefs toward the character. Microsoft Excel was used to randomly allocate participants to one of four groups. Each group of participants was emailed a link to an online survey that contained the vignette corresponding to their group. Participants were instructed to carefully read the vignette and were then International Journal of Eating Disorders 47:2 189–195 2014
BELIEFS ABOUT ANOREXIA AND MUSCLE DYSMORPHIA TABLE 1. Descriptive statistics for each item assessing potentially stigmatizing attitudes and beliefs toward the characters as a function of character diagnosis, character sex, and participant sex Character Diagnosis Anorexia Nervosa Item 1. They are feminine 2. They are masculine 3. They are weird 4. They are intelligent 5. They are a danger to others 6. They are a narcissist 7. They are self-destructive 8. They have self-control 9. They are likeable 10. They are heterosexual 11. They are similar to me 12. They will recover easily 13. Others willing to be friends 14. Strain on your friendship 15. You watch or monitor 16. Others watch or monitor 17. Likelihood of talking about their problem 18. Uncomfortable talking to them 19. Uncomfortable in social situations 20. Cautious not to upset 21. Responsible for their condition 22. Able to pull self together 23. Less competent 24. Using disorder to get attention 25. Physically fragile 26. Psychologically fragile 27. Discriminated against
Character Sex
Muscle Dysmorphia
Male
Participant Sex
Female
Male
Female
M
SD
M
SD
M
SD
M
SD
M
SD
M
SD
2.63 2.54 2.10 2.87 2.01 2.73 3.49 3.12 3.21 3.09 2.48 2.51 3.07 2.42 3.80 3.35 3.45 2.45 1.99 3.14 2.50 2.43 2.44 1.88 2.88 3.57 2.73
1.04 0.77 0.88 0.63 0.90 0.83 0.92 1.03 0.69 0.55 1.09 0.87 0.71 0.94 0.96 0.84 1.03 1.04 1.02 1.04 0.99 1.03 0.68 0.93 1.05 0.98 0.96
2.43 3.34 2.26 3.14 1.87 2.78 3.09 3.38 3.33 3.06 2.40 2.83 3.05 2.13 3.14 2.79 2.98 2.43 1.78 2.75 2.42 2.53 2.69 2.01 2.08 3.32 2.61
0.94 0.82 0.88 0.50 0.75 0.85 0.87 0.98 0.63 0.38 1.01 0.72 0.71 0.98 1.13 0.97 1.06 1.04 1.04 1.14 0.94 0.94 0.69 0.91 0.97 0.94 0.97
1.98 3.18 2.12 3.06 1.88 2.85 3.25 3.24 3.23 3.06 2.49 2.79 3.14 2.23 3.35 2.91 3.18 2.29 1.88 2.85 2.42 2.51 2.53 1.98 2.37 3.32 2.52
0.79 0.81 0.82 0.54 0.80 0.82 0.90 1.03 0.65 0.49 1.02 0.86 0.70 0.93 1.16 0.96 1.08 1.02 1.08 1.14 0.97 1.04 0.69 0.97 0.98 1.04 0.96
3.08 2.72 2.23 2.95 1.99 2.66 3.32 3.27 3.31 3.08 2.40 2.56 2.98 2.32 3.58 3.22 3.24 2.58 1.90 3.03 2.50 2.45 2.62 1.91 2.58 3.56 2.81
0.87 0.91 0.94 0.62 0.85 0.85 0.94 1.00 0.67 0.45 1.08 0.75 0.71 1.01 1.03 0.92 1.06 1.04 0.99 1.07 0.95 0.93 0.70 0.87 1.19 0.87 0.95
2.53 3.06 2.46 2.96 1.88 2.97 3.20 3.23 3.13 3.15 2.46 2.80 2.93 2.18 2.96 2.79 2.92 2.48 1.79 2.73 2.60 2.65 2.63 2.14 2.47 3.29 2.62
0.96 0.87 0.87 0.55 0.77 0.90 0.93 1.00 0.59 0.49 1.02 0.83 0.72 0.95 1.08 0.94 1.16 1.02 1.02 1.09 0.93 1.01 0.72 1.06 1.12 0.98 1.00
2.52 2.90 2.04 3.03 1.97 2.65 3.33 3.27 3.33 3.03 2.44 2.61 3.12 2.33 3.71 3.21 3.36 2.42 1.93 3.05 2.40 2.40 2.54 1.86 2.47 3.52 2.69
1.01 0.90 0.86 0.60 0.86 0.79 0.91 1.02 0.68 0.46 1.06 0.80 0.70 0.98 1.02 0.93 1.00 1.05 1.04 1.09 0.97 0.96 0.68 0.83 1.08 0.96 0.95
Bold indicates statistically significant main effects after using Hochberg’s step-up procedure to control the family-wise error rate at 0.05.
asked questions about the character described in the vignette. Statistical Analyses. A series of univariate analysis of variances (ANOVAs) were conducted with character diagnosis, character sex and participant sex entered as independent variables, and the stigma items entered as dependant variables. The family-wise error rate was controlled at 0.05 using Hochberg’s step-up procedure.15 Effect sizes are given as partial-eta squared g2 and were interpreted using Cohen’s (1988) guidelines: small (g2 5 0.01), medium (g2 5 0.06), and large (g2 5 0.14).
Results Table 1 shows descriptive statistics for participants’ responses to the stigma items averaged across each level of each independent variable. The ANOVAs showed significant main effects for each independent variable, and significant interactions between character diagnosis and character sex, and between character diagnosis and participant sex. There were no significant three-way interactions, and no significant interactions between character sex and participant sex. Only significant findings were interpreted. International Journal of Eating Disorders 47:2 189–195 2014
Effects of Character Diagnosis
As shown in Figure 1, there was a large effect of character diagnosis on the perceived masculinity of the character, such that characters with muscle dysmorphia were rated as more masculine than characters with anorexia nervosa, F(1, 334) 5 101.54, p < 0.001, g2 5 0.23. Furthermore, the effect of character diagnosis on perceived masculinity was more pronounced for male participants than for female participants, F(1, 334) 5 8.43, p 5 0.004, g2 5 0.03. Characters with anorexia nervosa were rated as less intelligent, F(1, 334) 5 13.36, p < 0.001, g2 5 0.04, less competent than their peers, F(1, 334) 5 9.68, p 5 0.002, g2 5 0.03, and more selfdestructive, F(1, 334) 5 12.78, p < 0.001, g2 5 0.04, than characters with muscle dysmorphia. Participants further believed that characters with anorexia nervosa would place greater strain on their friendship, F(1, 334) 5 9.29, p 5 0.002, g2 5 0.03, were more likely to be watched or monitored by the participant, F(1, 334) 5 38.63, p < 0.001, g2 5 0.10, and by others, F(1, 334) 5 40.73, p < 0.001, g2 5 0.11, and were less likely to recover easily than characters with muscle dysmorphia, F(1, 334) 5 191
GRIFFITHS ET AL. FIGURE 1 Mean perceived masculinity as a function of character diagnosis (anorexia nervosa or muscle dysmorphia) and participant sex (male or female). Perceived masculinity was significantly greater for characters with muscle dysmorphia compared with characters with anorexia nervosa, and this effect was significantly more pronounced among male participants. Errors bars represent 95% confidence intervals.
7.88, p 5 0.005, g2 5 0.02, and less likely to recover easily than male characters, F(1, 334) 5 7.33, p 5 0.007, g2 5 0.02. Interestingly, male characters were rated as less likely to be discriminated against in the community, F(1, 334) 5 12.93, p < 0.001, g2 5 0.04, and this effect was stronger among female participants than male participants, F(1, 334) 5 8.16, p 5 0.005, g2 5 0.02. Effects of Participant Sex
Male participants rated characters as more weird, F(1, 334) 5 18.55, p < 0.001, g2 5 0.05, more narcissistic, F(1, 334) 5 11.72, p 5 0.001, g2 5 0.03, and more likely to be trying to get attention for themselves, F(1, 334) 5 7.51, p 5 0.006, g2 5 0.02, compared with female participants. In addition, male participants indicated that they were less likely to personally feel the need to watch or monitor the characters, F(1, 334) 5 42.17, p < 0.001, g2 5 0.11, believed it is less likely that others would feel the need to watch or monitor the characters, F(1, 334) 5 16.66, p < 0.001, g2 5 0.05, and were less likely to talk to the character about their problem, F(1, 334) 5 13.66, p < 0.001, g2 5 0.04, than female participants. 9.90, p 5 0.002, g2 5 0.03. Participants also reported that they would need to be more cautious not to upset characters with anorexia nervosa compared to characters with muscle dysmorphia F(1, 334) 5 14.97, p < 0.001, g2 5 0.04. Finally, participants were more likely to talk to characters with anorexia nervosa about their problem than characters with muscle dysmorphia F(1, 334) 5 20.77, p < 0.001, g2 5 0.06, and this effect was more pronounced when the character was male rather than female, F(1, 334) 5 7.47, p 5 0.007, g2 5 0.02. Characters with anorexia nervosa were also perceived as more physically fragile than characters with muscle dysmorphia, F(1, 334) 5 51.09, p < 0.001, g2 5 0.13, and this effect was more pronounced for female characters, F(1, 334) 5 10.48, p 5 0.001, g2 5 0.03. Effects of Character Sex
As expected, male characters were rated as more masculine, F(1, 334) 5 23.70, p < 0.001, g2 5 0.07, and less feminine than female characters, F(1, 334) 5 121.61, p < 0.001, g2 5 0.27. Participants believed that female characters were more likely to be watched or monitored by others, F(1, 334) 5 10.79, p 5 0.001, g2 5 0.03, more uncomfortable to talk to about their problem, F(1, 334) 5 9.45, p 5 0.002, g2 5 0.03, more psychologically fragile, F(1, 334) 5 192
Discussion This study aimed to investigate young peoples’ stigmatizing attitudes and beliefs about men and women with anorexia nervosa and muscle dysmorphia. Overall, characters with anorexia nervosa were more stigmatized than characters with muscle dysmorphia. The former were rated as less intelligent, more self-destructive, less competent than their peers, more likely to strain the participants’ friendship, more likely to prompt cautious behaviour from the participant, more likely to be watched or monitored by the participant and by others, and less likely to recover easily compared to characters with muscle dysmorphia. In addition, participants were more likely to talk to characters with anorexia nervosa about the problem, especially when the character was male, and characters with anorexia nervosa were rated as more physically fragile, especially when the character was female. Thus, it seems that anorexia nervosa may engender harsher stigmatization than muscle dysmorphia. Alternatively, muscle dysmorphia might have been perceived more favourably than anorexia nervosa because young people may be relatively less familiar and/or knowledgeable about muscle dysmorphia, making them less likely to associate International Journal of Eating Disorders 47:2 189–195 2014
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symptoms of muscle dysmorphia with mental illness. Given that mental illnesses in general attract stigma,5 this could have translated into lesser stigmatization of muscle dysmorphia. Nevertheless, both explanations have clinical implications. If anorexia nervosa is indeed more stigmatized, this would probably impede treatment seeking. Alternatively, if people with muscle dysmorphia are perceived as having “less” of a mental illness than anorexia nervosa, sufferers may internalise that they do not have a “real disorder”, again impeding treatment seeking. However, differences in participants’ level of knowledge about the diagnoses are unlikely to explain the strong evidence found in this study that anorexia nervosa and muscle dysmorphia are perceived as a “female problem” and “male problem,” respectively. The large effect of character diagnosis on the perceived masculinity of the character was such that characters with anorexia nervosa were perceived as considerably less masculine than characters with muscle dysmorphia; an effect that was stronger for male participants. Interestingly, however, there was no significant effect of character diagnosis on perceived femininity. It seems that the extent to which anorexia nervosa and muscle dysmorphia are gender stereotyped may be much more strongly linked to how masculine each condition is perceived, rather than how feminine. Indeed, the effect size of character diagnosis on masculinity was over three times larger than the effect size for character sex, indicating that the contribution of one’s biological status as a male or female is overshadowed by one’s thinness- or muscularity-oriented psychopathology in terms of how masculine oneself is perceived. Interestingly, research has shown that conformity to traditional masculine norms is higher in men with muscle dysmorphia than in men with anorexia nervosa,16 and that conformity to traditional norms is more generally associated with muscle dissatisfaction among males.17 However, men with anorexia nervosa and healthy control men report equal conformity to masculine norms.16 Overall, female characters were more stigmatized than male characters. Female characters were rated as more psychologically fragile, more uncomfortable to talk to, more likely be watched or monitored by others, and less likely to recover easily, compared with male characters. Some of these findings fall in line with gender stereotypes, namely that females are more psychologically fragile. Others, such as the belief that females would be more uncomfortable to talk to, point to potentially damaging elements of interpersonal stigma that International Journal of Eating Disorders 47:2 189–195 2014
may be exacerbated among females with eating disorders. Interestingly, male characters were believed to be less likely to face discrimination in the community than female characters, contrary to most assumptions, and this effect was stronger among female participants. Male participants stigmatized characters more than female participants. Male participants believed characters were weirder, more narcissistic, more likely to be trying to get attention for themselves, less likely to be watched or monitored by the participant and by others, and less likely to be talked to by the participant about their problems. These findings are inconsistent with previous research by Wingfield et al.9 who found that male and female participants were mostly equivalent in their beliefs toward characters with eating disorders. However, the findings are consistent with those of Mond and Arrighi,12 who found that young males considered anorexia nervosa to be a less serious condition than young females. The current findings extend the sex difference in perceived severity of eating disorders to also include muscle dysmorphia. Several limitations of this study are noted. First, participants were undergraduate psychology students rather than a general population sample of young people. Psychology students may be more knowledgeable of anorexia nervosa and muscle dysmorphia, and perhaps, less likely to have—or be willing to report—stigmatizing attitudes and beliefs, limiting the generalizability of the current findings. Second, the vignettes were not pilot tested by experts in the field to determine whether they were representative of the respective disorders they were aimed at describing. However, this limitation is qualified by the lack of consensus surrounding the diagnostic criteria for muscle dysmorphia, and by the fact that the anorexia nervosa vignette used in the current study was closely based on anorexia nervosa vignettes used in previous stigma research. Third, the contribution of participants’ level of knowledge about muscle dysmorphia and anorexia nervosa to stigmatization was not investigated.
Conclusion We investigated young peoples’ beliefs and attitudes toward men and women with anorexia nervosa and muscle dysmorphia using a vignette paradigm. Characters with anorexia nervosa were more stigmatized than characters with muscle dysmorphia, female characters were more stigmatized than male characters, and male participants were 193
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more stigmatizing than female participants. There was strong evidence to suggest that anorexia nervosa and muscle dysmorphia are stigmatized as a “female” and “male” condition in line with societal gender role expectations, and this stigmatization is tied more strongly to perceptions of sufferers’ masculinity than to femininity.
References 1. Robinson KJ, Mountford VA, Sperlinger DJ. Being men with eating disorders: Perspectives of male eating disorder service-users. J Health Psychol 2013;18: 176–186. 2. Pope HG, Gruber A, Choi P, Olivardia R. Muscle dysmorphia: An underrecognized form of body dysmorphic disorder. Psychosomatics 1997;38:548–557. 3. Murray SB, Rieger E, Touyz SW, de la Garza Garcıa Y. Muscle dysmorphia and the DSM-V conundrum: Where does it belong? A review paper. Int J Eat Disorder 2010;43:483–491. 4. Crisafulli MA, Holle Von A, Bulik CM. Attitudes towards anorexia nervosa: The impact of framing on blame and stigma. Int J Eat Disorder 2008;41: 333–339. 5. Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of people with mental illnesses. Brit J Psychiat 2000;177:4–7. 6. Mond JM, Robertson-Smith G, Vetere A. Stigma and eating disorders: Is there evidence of negative attitudes towards anorexia nervosa among women in the community? J Ment Health 2006;15:519–532. 7. Roehrig JP, McLean CP. A comparison of stigma toward eating disorders versus depression. Int J Eat Disorder 2010;43:671–674. 8. Olivardia R, Pope H, Hudson J. Muscle dysmorphia in male weightlifters: A case-control study. Am J Psychiat 2000;157:1291–1296. 9. Wingfield N, Kelly N, Serdar K, Shivy VA, Mazzeo SE. College students’ perceptions of individuals with anorexia and bulimia nervosa. Int J Eat Disorder 2011;44:369–375. 10. Haldeman D. Gender atypical youth: Clinical and social issues. School Psychol Rev 2000;29:192–200. 11. Lee EAE, Troop-Gordon W. Peer processes and gender role development: Changes in gender atypicality related to negative peer treatment and children’s friendships. Sex Roles 2011;64:90–102. 12. Mond JM, Arrighi A. Gender differences in perceptions of the severity and prevalence of eating disorders. Early Interv Psychiatry 2011;5:41–49. 13. Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJV. Beliefs of women concerning the severity and prevalence of bulimia nervosa. Soc Psych Psych Epid 2004;39:299–304. 14. Stewart M, Keel PK, Schiavo RS. Stigmatisation of anorexia nervosa. Int J Eat Disorder 2006;39:320–325. 15. Hochberg Y. A sharper Bonferroni procedure for multiple tests of significance. Biometrika 1988;75:800–802. 16. Murray SB, Rieger E, Karlov L, Touyz SW. Masculinity and femininty in the divergence of male body image concerns. J Eat Disorder 2013;1:11. 17. Blashill A. Gender roles, eating pathology, and body dissatisfaction in men: A meta-analysis. Body Image 2011;8:1–11.
Appendix A : Vignette – Female with Anorexia Nervosa Meet Kelly. Kelly is a 19-year-old college student. Although mildly overweight as an adolescent, Kelly’s current weight is well below the normal range for her age and height. However, she thinks that she is overweight. She recently joined a fitness program at the gym and started running daily. 194
Through this effort, she has begun to lose weight. Kelly has also begun to “diet”, avoiding all fatty foods, restricting her food intake by skipping meals, and eating small set amounts of “healthy foods” each day, mainly fruit and vegetables and bread or rice. On occasions, Kelly finds it difficult to control her eating but then she redoubles her efforts to overcome her temptation, eating even less than she usually does and exercising even more. In addition, she has developed an intense fear of gaining any weight.
Vignette – Male with Anorexia Nervosa Meet Michael. Michael is a 19-year-old college student. Although mildly overweight as an adolescent, Michaels’s current weight is well below the normal range for his age and height. However, he thinks that he is overweight. He recently joined a fitness program at the gym and started running daily. Through this effort, he has begun to lose weight. Michael has also begun to “diet”, avoiding all fatty foods, restricting his food intake by skipping meals, and eating small set amounts of “healthy foods” each day, mainly fruit and vegetables and bread or rice. On occasions, Michael finds it difficult to control his eating but then he redoubles his efforts to overcome his temptation, eating even less than he usually does and exercising even more. In addition, he has developed an intense fear of gaining any weight.
Vignette – Female with Muscle Dysmorphia Meet Kelly. Kelly is a 19-year-old college student. Although mildly underweight as an adolescent, Kelly’s current weight is well above the average range for her age and height. Her body is muscular with little body fat. However, she thinks that she is underweight and “scrawny”. She recently began extra weightlifting sessions at the gym and started running daily. Through this effort, she has begun to gain more muscle and muscle definition. Kelly has also begun to “diet”, avoiding all fatty foods and eating large amounts of “healthy foods” each day. On occasions, Kelly finds it difficult to control her eating and workouts, but then she redoubles her efforts to overcome her temptations, adhering strictly to her diet and exercising even more. In addition, she has developed an intense fear of losing her muscle mass.
Vignette – Male with Muscle Dysmorphia Meet Michael. Michael is a 19-year-old college student. Although mildly underweight as an International Journal of Eating Disorders 47:2 189–195 2014
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adolescent, Michael’s current weight is well above the average range for his age and height. His body is muscular with little body fat. However, he thinks that he is underweight and “scrawny”. He recently began extra weightlifting sessions at the gym and started running daily. Through this effort, he has begun to gain more muscle and muscle definition. Michael has also
International Journal of Eating Disorders 47:2 189–195 2014
begun to “diet”, avoiding all fatty foods and eating large amounts of “healthy foods” each day. On occasions, Michael finds it difficult to control his eating and workouts, but then he redoubles his efforts to overcome his temptations, adhering strictly to his diet and exercising even more. In addition, he has developed an intense fear of losing his muscle mass.
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