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They arrive because the drinking has become a problem. Or because they train every day and their partner has finally said something. Or because a relationship is failing and they cannot work out why. Food is not on the list. It has often never been on the list.

This is the difficulty with eating disorders in men. They tend to be hidden inside something that looks like a different problem or inside something that looks like no problem at all.

A man who drinks every evening will eventually be asked about it. A man who trains every evening gets congratulated.

That is the trap. Discipline and willpower are admired, and rightly so. But for some men the gym is not discipline. It is a prison. It is not something they choose each day; it is something they cannot get out of. The commitment other people praise is the thing holding them in.

There is a simple test, and you can run it on yourself this week. Do not go once. Stay at home and sit with how you feel.

If that is harder than going, that tells you something. And if it is genuinely unthinkable, that tells you more. For some men, missing a single session would be the greater act of willpower by far.

The gym is only one of the shapes this takes, and it happens to be the one that gets applauded. There are others.

There is the man who has been dieting for twenty years and is still the largest person in every room he walks into. He knows more about nutrition than most clinicians. He has started again on a Monday more times than he can count. Nobody around him thinks of this as an eating disorder; they think of him as someone who ought to try harder. So does he.

And there is the man who gets the joke in first. He comments on his stomach before anyone else can. He is the one who makes himself the punchline in the changing room, and he is good company about it. That is not confidence. It is a man taking charge of the one humiliation he knows is coming, because owning it hurts less than receiving it.

Those three look nothing alike. One is admired, one is judged, one is good value at a party. The struggle underneath is identical. Food, weight and shape are being used to avoid feeling something, and an entire complicated life is being narrowed down to a single measurement.

That narrowing is not a side effect. It is the function. It is far simpler to be at war with your body than to sit with the questions a life keeps putting in front of you, about work, intimacy, meaning, getting older. A number is a problem with a clear answer. The rest is not.

This is a composite, drawn from many years of this work rather than from any one person.

Picture a man of forty-three. He is not in any visible difficulty. He has a job people respect and a marriage that is quiet rather than unhappy, and he is in better shape than most men his age. His colleagues make admiring remarks about the discipline.

He comes to see me because his wife said something. Not about food, about the gym. He goes six days a week, sometimes seven, and he has started arranging holidays around whether there is one. He describes this with a kind of embarrassed pride, because he knows how it sounds, and he also believes it is a virtue.

Food comes up in the fourth session, not the first. He eats the same seven things. He weighs them. If he eats outside that, the next day is longer in the gym to correct it, and he does not experience this as punishment; he experiences it as arithmetic. He has never once used the word 'diet', and he would reject the word 'disorder' outright.

What he will eventually say, if the room holds steady long enough, is that he has not wanted sex in about two years and has concluded there is something wrong with him as a man. He has not told his GP, because the conversation would have to begin somewhere he cannot begin it. He has not told his wife either, so she has drawn her own conclusion, and that is the real reason the marriage is quiet.

Everything in that picture is treatable. Most of it reverses. But none of it gets looked at, because every visible part of it is behaviour the world applauds.

Go back to that extra session, the one correcting yesterday. He experiences it as arithmetic. It has a clinical name, and it is one he would never apply to himself.

Most people believe bulimia means eating and then vomiting. It does not. The criteria require bingeing and then compensating to prevent weight gain, and the compensatory behaviours have always included excessive exercise, alongside vomiting, laxatives and fasting. Purging calories through the gym is purging. The structure is identical: take in a large amount, then undo it.

This is one of the main reasons men go unrecognised, and one of the main reasons they never refer themselves. A man who has never made himself sick is quite certain he does not have bulimia, and so is everyone around him. What he has, as far as anyone can see, is a training regime. What he actually has is a binge and a compensation, and because the compensation happens in a gym rather than a bathroom, it gets admired rather than noticed.

So I would ask anyone working with men to hold the question open a little longer. Not "Is he making himself sick?" but "What happens the day after he eats more than he meant to?"

Men feel ashamed of their bodies, and through their bodies, ashamed of their masculinity itself. What cannot be said out loud is not "I'm worried about how I look." It is closer to: I don't feel like a man, and my body keeps proving it.

That takes a different shape depending on whether a man is on his own or with someone, though it comes from the same place.

For a man on his own, it is visible in what does not happen. He does not approach the person he is attracted to, or he approaches expecting to be turned down and is. He needs a drink before he can be seen naked.

Inside a marriage it is quieter and much harder to see. Desire goes quiet, or his body does not respond, and he takes that as the final verdict on himself. Rather than say any of this, he withdraws. His wife, having nothing else to go on, concludes that he has either stopped wanting her or is seeing someone else. Neither is true. He will not correct her, because correcting her would mean explaining, and the explanation is the very thing he cannot say. That is how a marriage becomes quiet without anybody deciding anything.

Speaking would also mean stepping out of whichever role is keeping him safe, and every one of these men has one. That is why nothing gets said for years.

When a man trains hard and eats too little for what he is doing, his body lowers testosterone to conserve energy. Low desire and difficulty with erections follow from that directly. Sports medicine calls this relative energy deficiency, and it is a fuel problem, not a character problem.

So the discipline he is using to feel more like a man is quietly taking his masculinity from him. The part I most want men to hear: it reverses. Eat more, train less, and the body comes back.

I want to be clear first, because this argument gets heard as a position it is not. These medications are a genuinely good thing. For someone with a cardiac problem, with diabetes, with a real medical indication, they do something valuable and I have no argument with them.

But using them to treat an eating disorder is like treating the hair loss and calling it cancer treatment. It addresses the visible part. It does not address the underlying issue.

For a man with an eating disorder, weight and shape are not really about weight and shape. They have become a way of regulating himself, of finding safety, and above all a shield: against the world, and against his own feelings. While he is occupied with his body, he is not in contact with anything else. This is not a side effect of the preoccupation; it is its purpose.

This is also why the medication so often disappoints this particular group. Drugs like Ozempic and Mounjaro suppress hunger and produce fullness. But a man with an eating disorder eats for reasons other than hunger and continues eating even when full. He eats to avoid how he feels. Remove hunger, and the reason remains, so the result is often not relief but despair.

What I see instead is that the behaviour moves. One man I worked with began a prescription and, within weeks, started vaping. More commonly it goes to compulsive masturbation. The regulating has to happen somewhere, and if food is chemically closed off it simply finds another door.

None of this is an argument against prescribing. It is an argument for one question before the prescription: not what the man weighs, but what the eating is doing for him. A man who cannot answer that is unlikely to be helped by having his appetite removed.

There is one more turn to this journey, and it is the part that costs the most.

Almost every man I see in this position is living in preparation. Not now, but when. When the weight is down. When the body is right. Then he will go out properly, or date, or take his shirt off on a beach, or apply for the thing he wants, or be easier to live with. The present is a waiting room. Real life is understood to begin on the far side of an imaginary body.

That body never arrives, because it was never really a weight. It is a condition of being acceptable, and it moves exactly as fast as he does. Men who reach their target number often discover, within a few weeks, that the number has quietly changed.

So the years spent waiting are simply wasted. That is the true cost, more than the training or the food: a decade of ordinary life postponed against a condition that cannot be met. Whatever meaning might have been built in that decade was never permitted to begin, because meaning was not allowed to count until the body was right.

It is also why I am wary of any intervention aimed straight at the weight. It can look a great deal like progress while leaving the waiting room completely intact.

I wish I could tell you which treatment works. Nobody can say in advance whether therapy, or this particular therapy, or something else will be the thing that helps you.

What I know is that it comes down to trying. Something that doesn't work is still useful. It's information. Only the people who stop trying fail. There is no single thing that works for everyone, and finding yours takes more than one attempt.

Start by saying it out loud to one person. That is usually the hardest part, and it counts as treatment.

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