Body dissatisfaction and disordered eating among men who have sex with men in Canada.
Article Type: Report
Subject: Eating disorders (Risk factors)
Eating disorders (Research)
Child sexual abuse (Risk factors)
Child sexual abuse (Research)
Homophobia (Psychological aspects)
Authors: Brennan, David J.
Crath, Rory
Hart, Trevor A.
Gadalla, Tahany
Gillis, Loralee
Pub Date: 09/22/2011
Publication: Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Men's Studies Press ISSN: 1532-6306
Issue: Date: Fall, 2011 Source Volume: 10 Source Issue: 3
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Canada; United States Geographic Code: 1CANA Canada; 1USA United States
Accession Number: 275636581
Full Text: Evidence suggests that gay, bisexual and other men who have sex with men (MSM) score higher than heterosexual-identifying men on disordered eating symptomology (DES). This exploratory study examined if the following psychosocial factors were associated with DES among a diverse sample of MSM: race, age, sexual identity, sexual risk, substance use, depression, history of childhood sexual abuse (CSA) and internalized homophobia. Using cross sectional data collected at "Pride Toronto 2008" (N = 383), multivariate analysis revealed the following factors to be associated with DES: CSA, depression, being White (vs. Black or Asian), being younger, and engaging in behaviours to increase muscle mass. These results may inform the development of useful and efficacious interventions to reduce the risks associated with body dissatisfaction and DES among MSM.

Keywords: eating disorders, body dissatisfaction, gay and bisexual men, drive for muscularity

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There has been an increased interest in exploring the prevalence of eating disorder symptomology and body dissatisfaction amongst heterosexual, gay and bisexual identifying male populations, together with the various factors that put men at risk for these detrimental health behaviours. Recent studies indicate that North American men have increasingly unhealthy preoccupations with their bodies, traits that once were considered the sole purview of women (Siconolfi, Halitis, Allmong, & Burton, 2009). Indeed, rates of body dissatisfaction among men have increased from 10 %to 43% over the past 30 years (Goldfield, Blouin, & Woodside, 2006; O'Dea & Abraham, 2002), which are close to rates of approximately 50% found among North American women (Garner, 1997).

Given that body dissatisfaction has been considered a plausible catalyst for disordered eating symptomology (DES; O'Dea & Abraham, 2002), there is a growing concern that men may also be at increased risk for DES. Prevalence of DSM-IV anorexia nervosa, bulimia nervosa and binge eating disorder in American and Canadian studies have been estimated as 0.9%, 1.5% and 3.5% respectively among women, and 0.3%, 0.5%, and 2.0% among men (Hudson, Hiripi, Harrison, Pope, & Kessler, 2007). Several studies, however, suggest the literature is limited by problems with under-diagnosis, misdiagnosis, and under treatment of men's eating disorders (Harvey & Robinson, 2003; Weltzin, Weisensel, Franczyk, Burnett, Klitz, & Bean 2005) and thus, the prevalence of DES amongst men might be higher than what is revealed by these estimates (Gentile, Raghavan, Rajah, & Gates, 2007; O'Dea & Abraham).

When sexual orientation and sexual behaviour have been accounted for in research on DES among men, there is an indication that gay and bisexual men (GBM) and other men who have sex with men (MSM) score significantly higher than heterosexual identifying men on both body dissatisfaction ratings and eating disturbance ratings (Beren, Hayden, Wilfley, & Grilo, 1996; Kaminski, Chapman, Haynes, & Own, 2005; Siever, 1996; Strong, Williamson, Netemeyer, & Geer, 2000; Williamson & Hartley, 1998). Factors associated with body dissatisfaction and DES among MSM include a desire for thinness (Meyer, Blissett & Oldfield, 2001 ; Picot, 2004; Siever, 1994; Williamson, 1999), and propensities to over-fixate on muscularity and on attaining an ideal masculine physique (Kaminski et al., 2005; Kimmel & Mahalik, 2005; Picot, 2004; Yelland & Tiggemann, 2003).

Recent attempts have been made to offer plausible explanations of observed association between being male, sexuality, sexual expression and MSM/GBM's lived psychosocial realities and DES. In much health-based literature there has been a tendency to focus on psychological factors that are either found to be associated with, or are proposed as possibly contributing to a propensity for DES. A comparative gender study by Gadalla and Piran (2007), for example, which did not account for sexual identity or behaviour, found a strong association between DES and depressive disorders among men. These findings are consistent with results reported in a study by Woodside et al. (2001), identifying an association between psychiatric diagnoses (major depression, social anxiety, social phobia and simple phobia) and DES among men. In addition, substance and alcohol use has been associated with DES among males and females sampled in Canadian and American national survey data (Gadalla & Piran, 2007; National Centre on Addiction and Substance Abuse, CASA 2003). Several studies that specifically focused on MSM suggest that these psychological manifestations may be linked to the lived experiences of being gay- or bisexual-identifying or having the experience of being a man who has sex with other men. Specifically, experiences associated with systemic homophobia--such as stigma, internalized homonegativity, fear of being physically attacked--have been linked with body dissatisfaction (Kimmel & Mahalik, 2005; Levesque & Vichesky, 2006) and place men at risk for DES (Russell & Keel, 2002; Swearingen, 2006; Torres, 2008). Other studies have traced connections between systemic homophobia that couples the stereotypical feminine with homosexuality, and the overcompensating behaviours and identifications of GBM/MSM with a stereotypical masculine body comportment to prove their masculinity despite the orientations of their sexual desire (Meyer, Blissett & Oldfield, 2001 ; Pope et al., 2000; Russel & Keel, 2002).

Further, the literature suggests that MSM are more likely to have experienced sexual abuse and victimization than heterosexual men (Balsam, Rothblum, & Beauchaine, 2005; Corliss, Cochran, & Mays, 2002) and that men with this history are at greater risk for DES than men who did not experience childhood sexual abuse (Feldman & Meyer, 2007a). Other research has demonstrated that experiences of childhood sexual abuse place MSM at risk for other detrimental health behaviours and experiences, including being HIV positive, and risky substance use (Brennan, Hellerstedt, Ross, & Welles, 2007).

In addition, age has been shown to be associated with DES. Feldman and Meyer (2007b) report that MSM aged 18 to 29 were significantly more likely to have subclinical bulimia than men aged 30 to 59. Further, Kimmel and Mahalik (2005) and Siever (1994) suggest a desire to hold onto an ideal body physique connected with youthfulness might put older gay men at risk for body dysmorphia. Finally, a study by Kraft, Robinson, Nordstrom, Bockting, and Rosser (2006) examining the association between body weight, body image and unsafe sexual behaviour among MSM concluded that non-obese men (as measured by a lower BMI) and younger men were more likely to engage in unsafe sexual behaviours, and that normal weight-ranged men and younger men were more likely to have anal sex. No positive association was found between body dissatisfaction and unsafe sex. In conclusion, the authors suggest that the appearance of health (i.e., not "HIV-infected") as signalled by muscularity and/or thinness, might be a factor in persuading sexual partners to forgo condom use during anal sex (Kraft, et al., 2006). Similar results were also reported by Allensworth-Davies, Welles, Hellerstedt, and Ross (2008).

Findings are inconsistent as to whether ethnic and racial minority men have greater or less DES. Picott (2006) found that Caucasian men had more body dissatisfaction and eating pathology than African-American men. Ricciardelli, McCabe, Williams, and Thompson's (2007) review of the literature on the relationship between ethnic/racial identity (as a demographic characteristic) and men's eating disorders and body image demonstrated that African-American men preferred a larger body type, had a more positive body image and were less likely to perceive themselves as overweight than white men. They also found that Latino men had no significant differences in body image than white men and were also less likely to report being overweight. Asian men reported inconsistent evidence across studies and what few studies that exist indicated that First Nations/American Indian males had a propensity for disordered eating attitudes and negative associations with their bodies. However, sexual orientation was not accounted for in any of this literature reported by Ricciardelli et al. In contrast, Feldman and Meyer (2007b) found that Latino and African American MSM had a higher prevalence of eating disorders than their white counterparts.

More sociologically oriented factors have also been suggested as plausible explanations of, or have been identified as being possibly associated with DES and body dissatisfaction. Several authors, for example have pointed to the effects that increased exposure to mainstream gay media (advertising, magazines/newspapers, pornography, films), with their emphasis on sculpted, lean yet muscular bodies, can have on men's desire to orient their body perceptions and their perceptions of other men around these mostly unattainable body ideals (Duggan & McCreary, 2004; Hartoum & Belle, 2004; Harvey & Robinson, 2003; Morgan & Arcelus, 2009; Morrison, Morrison, & Hopkins, 2003). Other literature has focused on the importance within gay communities for men to signify a "healthy body" as a counterweight to the stigmatizing force of HIV/AIDS phobia (Diaz, 2006; Ramsay, Catalan, & Gazzard, 1992; Varas Diaz, Toro-Alfonso, & Serrano-Garcia, 2005). Finally, numerous authors have highlighted the possibility that there exists a tremendous amount of peer and culturally manifested pressure to conform to the constructs of an idealized physique that have become normative in mainstream, white gay communities. If social acceptance and the ability to be sexually intimate with other men are understood to hinge on achieving a lean, muscular form, then attempts to conform to or attain this impossible-for-most ideal may, these authors suggest, lead to body dissatisfaction and negative body practices (Morgan & Arcelus, 2009; Morrison, Morrison, & Hopkins, 2003; Yaeger, 2000).

The present study attempts to further probe the connections between psychosocial factors that may affect DES and compromise MSM's overall physical and psychological well being. Moreover, given that the majority of body dissatisfaction and DES research (prevalence and associated factors) has been American focused, we respond to a need to explore if similar patterns of behaviour occur in other national contexts. Our study was designed to estimate the prevalence of DES and level of body dissatisfaction among a sample of Canadian MSM who attended the Lesbian, Gay, Bisexual and Transgendered (LGBT) "Pride Toronto 2008" Festival. In addition, we analyzed factors that may be associated with eating disorders and body dissatisfaction, including demographics (age, race/ethnicity, education levels), depression, substance use, sexual risk behaviours, internalized homonegativity, and history of childhood abuse. Overall, this study fills important gaps in the literature and informs the need for, and the potential design of preventive interventions tailored to address the health and well-being of MSM in Canada.

METHOD

Procedure

Data for this study were gathered from a cross-sectional survey of MSM who attended the LGBT "Pride Toronto 2008" Festival (n = 510). Data collection took place over a two-clay period during the main weekend of Pride festivities. The Pride Toronto Festival is an annual social, cultural and political event that takes place at the end of 10 days of activities and events celebrating the diversity and strength of the greater Toronto LGBT communities. Attracting over a million people a year, the festival takes place in the downtown Toronto area, close to the city's Gay Village and is one of the world's largest LGBT celebrations (Pride Toronto, 2010).

Eligibility for inclusion in the study required that participants were over 16 years of age, identified as male (either biological or transgender), have had sex with a man over the last year, and resided in Ontario (the province where the study was conducted). A team of 30 racially diverse research assistants of varying ages and body shapes were deployed to approach potential participants in the festival crowd. As a means of correcting a tendency of previous festival based studies to sample men who were mostly white (Allensworth-Davies, Welles, Hellerstedt, Ross, M., 2008; Picot, 2006), research assistants were encouraged to recruit men who were diverse in terms of ages, body sizes and shapes, and race/ethnicities. Men who agreed to participate were screened for eligibility criteria, informed consent was obtained and participants were directed to a tent that was pitched on the festival grounds to ensure privacy for those completing the survey. The self-completed, anonymous survey took approximately 15 minutes of time to complete and participants received $15.00 cash compensation for their time. Recruitment and consent methodologies were approved by the Research Ethics Board of the University of Toronto and Ryerson University. Of those approached, 510 men completed the survey. Due to missing data for the variables of interest, the final study sample included 383 men. The only difference in demographics or the outcomes between those who participated and those who were excluded because of missing data (n = 127) was that those excluded were more likely to identify as Black (p = 0.01).

Measures

Respondent characteristics. We collected information about respondents' age, education (completed high school/at least some college), sexual orientation (gay/bisexual/heterosexual), ethnic and racial identities, coded into four categories--White, Black (African, Afro-Caribbean and Black-Canadian), Asian (South Asian, East Asian, and Southeast Asian), and Other (mixed, Aboriginal, Middle Eastern, Pacific Islander, Hispanic/Latino), current relationship status (single, monogamously coupled, non-monogamously coupled), HIV status (positive/negative/unknown). Body Mass Index (Garrow & Webster, 1985) was calculated based on participants' reported weight and height (weight (kg) / [height (m)]2). Respondents reported their frequency of alcohol use before or during sex in the last three months (none/moderate/regular) as well as their overall use (never/at least once) of drugs (marijuana, crystal methamphetamine, cocaine, special K, poppers, ecstasy, tranquilizers, and heroin) over the last three months.

Sexual behaviours. All participants were asked about protected and unprotected insertive and receptive anal intercourse over the last six months with primary or secondary/casual male partners who were of serodiscordant or unknown HIV status. Sexual risk was calculated as any unprotected serodiscordant anal intercourse (yes/no). Because of the increased chance of not truly knowing secondary partners' HIV status, all unprotected anal intercourse with non-primary partners was calculated as sexual risk.

Psychological factors. Respondents' propensities for depression were assessed using the Center for Epidemiologic Studies Short Depression Scale (CES-D 10; Andresen, Malmgren, Carter, & Patrick, 1994), a standardized scale using 10 items to assess for depression (a = .66 in this sample). Respondents completed the Internalized Homonegativity Scale (Bell & Weinberg, 1978) which measures participants' acceptance of negative views about their own same-gender sexual behaviour and/or identity (~ = .89 in this sample). Participants were also asked to report if, as a child, they were ever forced to have sex with others who were at least four years older (yes/no).

Drive for muscularity. Finally, respondents were asked items that were related to their experiences of body image and body image dissatisfaction. The Drive for Muscularity scale (DMS; McCreary & Sasse, 2000, 2007) is a scale developed for use with males and was employed in this study to test for pressure to be muscular (a = .89 in this sam pie). One item pertaining to anabolic steroid use was identified by the original authors as often having little variability in analysis resulting in detraction from the scale's reliability. This was true for our sample and therefore that item was excluded from our analysis, leaving a 14-item scale. In accordance with McCreary and Sasse's reported psychometrics, the DMS contains two subscales: 1) DMS Muscularity Oriented Body Image Attitudes, DMS Attitudes (a = .90 in this sample), a subscale that rated the idealization of muscularity such as "I wish that I were more muscular," and "I think I would feel more confident if I had more muscle mass," and 2) DMS Muscle Development Behaviors, DMS Behaviors (a = .85 in this sample) included items that tracked behaviours oriented towards gaining muscle mass such as "I feel guilty if I miss a weight training session," and "I drink weight gain or protein shakes." In order to capture the differences between lower scores and higher scores, both subscales were quartiled for analysis.

Disordered eating symptomology. Risk for DES was measured using the Eating Attitudes Test (EAT-26; Garner, Olmstead, Bohr & Garfinkle, 1982). The EAT-26 is a commonly used scale that has been validated on numerous populations and is designed to measure DES (a = .88 in this sample). For this scale, a score below or equal to 20 is considered low risk, and a score above 20 is considered high risk for DES. A high risk score is suggested by Garner et al. as cause for further diagnostic testing. Thus, the DES was scored as low risk and high risk.

ANALYSES

All data analyses were conducted using SPSS 17. Bivariate analyses were conducted using Z2 tests for categorical variables and ANOVAs for continuous variables to test for any potential associations between the dichotomous DES variable and the independent variables, thus DES was used as the grouping variable. Variables that were associated with eating risk were included in the regression model. As the potential associations were exploratory in nature, multivariate analyses were conducted using binary logistic regression (backward elimination) with reported odds ratios and 95% confidence intervals. In order to attempt to capture the full effects of the DMS scale and its subscales, the DMS scale was simultaneously run as a full scale in one model, and as two separate subscale scores in another model.

RESULTS

Descriptive Statistics and Correlations

As seen in Table 1, the sample was comprised of a racially diverse (40% non-Caucasian) group of men. This demographic, although slightly underestimating Asian residents, approximates the racialized composition of people living in the greater Toronto area (City of Toronto, 2010). The majority of respondents were well educated (82.5% having at least some level of college or university), single (54.3%) and under age 40 (69%). Most men identified as gay (88%) or bisexual (8%) with 3% identifying as heterosexual. Nearly 14% reported being HIV-positive and nearly 7% reported being unsure of their HIV status. In terms of serodiscordant sexual intercourse, just over one fifth of men reported engaging in sexual risk behaviour.

Nearly one-third of the sample (32.6%) reported a history of childhood sexual abuse. The CES-D 10 score mean was 9.95, (SD = 4.40; range 0-27). Scores on the Internalized Homonegativity scale were positively skewed with a median of 5.0 (IQR 4-9). The DMS Attitudes subscale had a mean of 3.54 (SD = 1.31; range 1.0 - 6.0), while DMS Behaviors was positively skewed (median = 1.86: IQR 1.43-2.57). Finally, DES was reported by 14% of respondents.

Bivariate analyses showed that a risk for disordered eating was associated with less education, ([chi square] (1, N = 383) = 7.35, p < .01), younger age ([chi square] (4, N = 383) = 11.57, p < .05), tranquilizer use (chi square] (1, N = 383) = 6.40, p = .01), increased frequency of alcohol use during sex ([chi square] (1,383) 7.37, p = .03) internalized homonegativity (F (1,381) = 5.87, p = .02), depression ( F (1,381)= 10.53, p = .01), DMS Attitudes (F (1,381) = 4.22, p < .05), DMS Behaviors (F (1,381) = 16.08, p < .001 ), an overall drive towards muscularity, DMS,(F (1,381) = 12.17, p = .001) and a history of CSA ([chi square] (1,383) = 6.52,p = 0.01). Internalized homonegativity was not significantly related to DES (p = .85).

Logistic Regression Analysis

All variables associated with DES as well as the demographic variables were entered in a backward elimination regression model to ascertain a parsimonious model to explain the relationships between the independent variables and current DES. We entered the DMS subscales separately to assess their independent relationship with DES. The seventh (final) model (Table 2) resulted in five significant predictors for DES among the sample. The following variables did not contribute significantly to the final model and were removed during the first six steps of the analysis: Body Mass Index, sexual risk, alcohol before/during sex, education, idealized muscularity, and homonegativity.

Those who reported a history of childhood sexual abuse were more than twice as likely to report DES (OR 2.16; 95% CI 1.09, 4.27). Both Black and Asian identifying men were less likely to report DES than their white counterparts (OR 0.26; 95% CI 0.08, 0.83; and OR 0.28; 95% CI 0.10, 0.77 respectively). Men between 31 and 40, and over 51 were less likely to report DES than men whose ages ranged between 16 and 24 (OR 0.25; 95% CI 0.08,0.73; OR 0.11; 95% CI 0.01,0.96). Those who reported the greatest propensity for drive to increase muscle mass (DMS behavior) were over eight times more likely to report DES (OR 8.14; 95% CI 3.03,21.87). We may also note that men associated with the second quartile grouping for propensity to adjust behaviours to amass muscle were also associated with DES (OR 3.4; 95% CI 1.15, 10.16). Depression was also found to be associated with DES, with those reporting higher depression scores being 8% more likely to report disordered eating attitudes (OR 1.08; 95% CI 1.01, 1.16). Finally, alcohol use during sex was not associated with DES in the final model.

DISCUSSION

The results of this study suggest that MSM report relatively high body dissatisfaction and risk for DES. Given that Gadalla and Piran (2007) reported that a prevalence rate of risk for eating disorders for men without regard to sexual orientation of 0.5% in a large Canadian health dataset, the present study suggests that Canadian MSM may be at greater risk for eating disorders than the general population. This has been reported in numerous other studies in the U.S., the Netherlands and Australia (Beren Hayden, Wilfley & Grilo, 1996; Kaminski, Chapman, Haynes & Own, 2005; Siever, 1994; Strong, Williamson, Netemeyer, & Geer, 2000; WichstrCm, 2006; Williamson, & Hartley, 1998; Yelland, & Tiggemann, 2003).

Consistent with prior research (Feldman & Meyer, 2007b), younger men reported significantly higher DES, when compared with some older men. However, caution needs to be exercised when interpreting these results given that what appears to be an effect of age could also represent a generational difference. By way of possible explanation for these findings, Drasin et al. (2008) and Williamson et al. (1998) have suggested that due to a confluence of cultural, political, sociological and technological factors, adolescent and young adult men, as a cohort, now have a myriad of ways of being exposed to gay mainstream subculture, opportunities that did not exist for even men who are 30 years of age and beyond. However, along with the sexual and social opportunities and benefits that this exposure provides come certain vulnerabilities. Precisely at the time when young men are forging an adult identity which, according to the development literature is generally understood to be a time of vulnerability, uncertainty and instability (Savin-Williams, 2005), young GBM and MSM are further laden with the challenges associated with the following socio-historically specific developmental milestones: (a) garnering a sense of belonging and acceptance in a hegemonic gay community that celebrates a white, youthful, lean body ideal (Boisvert & Harrell, 2009); (b) emotionally negotiating the process of disclosure of sexual orientation/behaviours; (c) navigating systemic and interpersonal homophobia; and (d) acknowledging, accepting and acting upon their sexual desires in a space where youthful lean bodies hold currency (Drasin et al., 2008; Williamson & Hartley, 1998). In other words, if systemic homophobia sets the stage for negotiating developmental milestones, enhanced exposure to hegemonic gay ideals may very well have resulted in the body being a preferred site in which young men are being invited to forge and perform an acceptable and accepted normative gay identity, or persona that is able to achieve sexual success with other men (Duncan, 2007). Obviously more research is needed to understand the complex linkages that are suggested here between systemic, intra-psychic and inter-personal forces and responses active in the lives of this generation of young men.

An association between a risk for disordered eating and a history of childhood sexual abuse has been reported relatively consistently among studies of adolescent and adult women (Smolak & Murnen, 2002; Van Gerko, Hughes, Hamill, & Waller, 2005). Only recently have researchers reported similar associations between CSA and DES among MSM (Feldman & Meyer, 2007a). The present study has corroborated this previous evidence by suggesting that the MSM in the sample who reported CSA were more than twice as likely to report DES. Though the present study did not assess for type of eating risk (i.e., bulimic, anorexic) previous work has identified CSA being more likely associated with bulimic symptoms than anorexic symptoms among both women (Van Gerko et al.) and MSM (Feldman & Meyer, 2007b). CSA has been also associated with other mental health issues among MSM including increased drug usage (Brennan, Hellerstedt, Ross, & Welles, 2007) anxiety, depression and sexual risk (Dilorio, Hartwell, & Hansen, 2002). Results from this study also corroborated the association between depression and DES. Borrowing from feminist scholarship, others have suggested that this linkage between CSA and DES and other mental health issues may result from men's attempts to use food, the body and/or alcohol/substances as compensatory mechanisms to help manage the vulnerability and overwhelming emotional states resulting from their abuse, or as tools of empowerment and as expressions of possessing and exercising control (Smolak & Murnen, 2002). Poor self esteem resulting from the abuse has been suggested as another plausible linkage to behaviours that are self punishing (like DES and possibly sexual risk behaviours; Feldman & Meyer, 2007a). We suggest the need to further probe the relationship between DES, CSA and other mental health factors among MSM.

In contrast to Feldman and Meyer's study (2007b), our results suggest that White identifying men might be at greater risk for DES than either Asian or Black identifying men. One possible explanation resides around the increased vulnerability that White identifying men may face when encountering media images and gay cultural norms that are oriented around an idealized White body of a specific stature and shape. In other words, racial identification with the idealized physique, as reinforced by peer pressure, may leave White identifying men especially vulnerable to the risks of body shame, fear of being evaluated and rejected, body dissatisfaction or adopting extreme measures to match normative assumptions about an idealized physique with own their own eating and body behaviours (Kozak, Roberts & Frankenhauser, 2009). Moreover, it is plausible that racialised men, depending on their levels of internalized racism (a higher level of internalised racism might signify a greater orientation towards the White idealised physique), their experiences of racism, and their strength of connection to their own ethno-racial communities (greater connection would represent a resiliency to the idealised physique), may or may not orient their conceptualizations of themselves or their behaviours in relation to these ideals. Caution must be exercised, though, when interpreting these findings.

Despite our findings, multiple experiences of racialised, economic and homophobic discrimination are known to have a deleterious impact on health outcomes (Cain & Kingston, 2003; Williams, Neighbors, & Jackson, 2003). However, when exploring issues of body image and disordered eating attitudes specifically, little empirical evidence exists to demonstrate differences or similarities between different ethno-racialised MSM (including White/Anglo MSM populations). While several studies demonstrate that Black men are less likely to experience body dissatisfaction than White counterparts (Falconer & Neville, 2000) or that Black men who experience greater body dissatisfaction are more likely to engage in unprotected anal intercourse (Wilton, 2009), other studies on other non White/Anglo racialised groups provide less conclusive results specifically with regards to Asian men (Ricciardelli, McCabe, Williams, & Thompson's, 2007). Problematic, perhaps, is the lack of known measurement tools developed specifically for ethno-racialised MSM that account for the effects of experiences of racialisation and community/ethnic/cultural attitudes on body satisfaction and eating behaviours and attitudes. Clearly, further research is needed to explore the possible associations between racialised and ethnic identity (including a White identity) and experiences of poverty and the health experiences of differently racialised groups of MSM.

MSM in this sample reported an increased drive for muscularity. Researchers have suggested this may be related to the impact of gender role norms and homophobia (Meyer, Blissett, & Oldfield, 2001). Though internalized homonegativity has been shown to be associated with body dysmorphia among MSM in other samples (Kimmel & Mahalik, 2005), no known study has examined the direct associations of internalized homonegativity with disordered eating attitudes and behaviours. We found no association in our sample. Other factors that were not associated with DES included education, depression, alcohol use during sex, tranquilizer use, BMI, sexual risk and having an idealized body image. Thus, although it does not appear that MSM who are at risk for DES may exhibit these characteristics, caution should be exercised when interpreting these results. Internalized homonegativity may be associated with pressures to conform to a masculine ideal and or the experience of stigma and discrimination, variables which were not assessed in the current study. Other research has reported a direct association between a drive for being more muscular, DES and a desire to be more masculine as well (Hospers & Jansen, 2005)--factors that have been linked to social anxiety and homonegativity in other studies (Martins, Tiggemann, & Kirkbide, 2007; Meyer, 2003). Finally, previous research has shown evidence of increased anxiety (Brennan et al., 2010) including social anxiety among MSM (Gilman, Cochran, Mays, Hughes, Ostrow, & Kessler, 2001), but this has not been examined in the context of body image. Given the increased pressure among MSM to achieve an idealized physique, further research would be needed to ascertain if there is a relationship between substance use, anxiety and body image dissatisfaction.

The full DMS scale was not significantly associated with DES; however, when analyzed as two separate subscales the highest quartile of the behavioural subscale is highly associated with DES even though the scores for DMS behaviour were lower on average than the scores for DMS attitudes. For MSM, engaging in behaviours to increase muscle mass is well documented in the literature (Chaney, 2008; Kaminski, et al., 2005; Swami & Tovee, 2008) although there may be a close link between the behavioural aspects of eating and increasing muscle mass. Further research is required to understand this possible association.

Study Limitations

This study reports some significant findings related to body dissatisfaction and eating risks among a diverse sample of MSM. However, it is important to acknowledge the limitations of the study in order to interpret these findings appropriately. As attendees of a large urban Pride festival, it cannot be assumed that the participants were representative of all MSM in the Toronto area. Those who attend the festival are more likely to be comfortable with a gay or bisexual identity. It is unknown if they are different in terms of attitudes towards their bodies or eating risks than other men who did not attend. We chose the festival venue because this allowed us to recruit a broad sample of the community without use of a clinical or sex-related venue (bar, bathhouse) where participants are more likely to report a variety of risks (sexual, mental health, etc.). Additionally, it is hoped that our use of 30 diverse volunteers to recruit men of various demographics and body types helped to increase the salience of the findings.

Finally, it should be noted that the CES-D 10-item scale was found to be only marginally reliable with this sample ([alpha] = .66). Although some researchers suggest this falls within an acceptable range for scales testing psychological behaviours (Kline, 1999), we suggest caution when considering the results of this study which demonstrate an association between depression and a propensity to have DES. It should also be noted that while our literature review revealed that the reduced, 10-item scale has been found to be reliable with a general population (Darnall et al., 2003; Kohout et al., 1993) our review did not locate a study in which the CES-D 10 item scale was tested with GBM or MSM. Further investigation is warranted to ascertain this scale's reliability with this population.

Implications for Practice and Conclusion

MSM face significant barriers in accessing health and social services (Mule, 2007; Tjepkema, 2008). Services that do exist most often focus on issues of HIV/AIDS to the neglect of other serious health issues that affect this population. Underreporting of DES and its association with other physical/mental issues including childhood sexual abuse are plausible negative consequences occurring in this current health environment. Service providers need to be aware not only of the risk of DES among MSM but potential precipitating social/psychological factors as well, in order to foster health environments where GBM/MSM feel comfortable, empowered and adequately resourced to explore the complexity of these issues.

Results from this study may be used to assist in the screening of potential risks among MSM. Furthermore, these results can help to inform the development of useful and efficacious interventions, such as counselling modules, holistic health workshops and psycho-educational groups in order to reduce the risks associated with body dissatisfaction and DES among these marginalized populations. In addition, there is a role for broad public education and advocacy in gay, bi, and MSM communities to address the social pressure that exists to conform to a certain body stereotype. Findings from this study can be incorporated into training for health professionals and LGBT public health education. Finally, it is hoped that these results will assist in the development of valid and reliable measurement instruments for these body dissatisfaction and DES outcomes among a variety of MSM populations, particularly men of various ethnoracial backgrounds.

DOI: 10.3149/jmh.1003.253

REFERENCES

Allensworth-Davies, D., Welles, S.L., Hellerstedt, W.L., & Ross, M.W. (2008). Body image, body satisfaction, and unsafe anal intercourse among men who have sex with men. Journal of Sex Research, 45(1), 49-56.

Andresen, E.M., Malmgren, J.A., Carter, W.B., & Patrick, D.L. (1994). Screening for depression in well older adults: Evaluation of a short form of the CES-D (Center for Epidemiologic Studies depression scale). American Journal of Preventive Medicine, 10, 77-84.

Balsam, K.F., Rothblum, E.D., & Beauchaine, T.P. (2005). Victimization over the life span: A comparison of lesbian, bisexual, and heterosexual siblings. Journal of Consulting and Client Psychology, 73(2), 477-487.

Bell, A., & Weinberg, M. (1978). Homosexualities : A study of diversity among men and women. New York: Simon & Schuster.

Beren, S.E., Hayden, H.A., Wilfley, D.E., & Grilo, C.M. (1996). The influence of sexual orientation on body dissatisfaction in adult men and women. International Journal of Eating Disorders, 20(2), 135-141.

Boisvert, J., & Harrell, A. (2009). Homosexuality as a risk factor for eating disorder symptamology in men. Journal of Men's Studies, 17(3), 210-225.

Brennan, D.J., Hellerstedt, W.L., Ross, M.W., & Welles, S.L. (2007). History of childhood sexual abuse and HIV risk behaviors in homosexual and bisexual men. American Journal of Public Health, 97(6), 1107.

Brennan, D.J., Ross, L.E., Dobinson, C., Veldhuisen, S., & Steele, L. (2010). Men's Sexual Orientation and Health in Canada, 101(3), 255-258.

Cain, V., & Kingston, R. (2003). Investigating the Role of racial/ethnic bias in health outcomes. American Journal of Public Health, 93(2), 191-92

Chaney, M.P. (2008). Muscle dysmorphia, self-esteem, and loneliness among gay and bisexual men. International Journal of Men's Health, 7(2), 157-170.

City of Toronto. (2010, Aug. 23). Toronto's racial diversity. Retrieved from http://www.toronto.ca Corliss, H.L., Cochran, S.D., & Mays, V.M. (2002). Reports of parental maltreatment during childhood in a United States population-based survey of homosexual, bisexual, and heterosexual adults. Child Abuse Neglect, 26(11), 1165-1178.

Darnall, B.D., Ephraim, P., Wegener, S.T., Dillingham, T., Pezzin, L., Rossbach, P., & MacKenzie, E.J. (2005). Depressive symptoms and mental health service utilization among persons with limb loss: Results of a national survey. Archives of Physical Medicine and Rehabilitation, 86(4), 650-658.

Diaz, R. (2006). In our own backyard. HIV stigmatization in the Latino Gay Community. In N.Teunis & G. Herdt (EDs). Sexual Inequality and social justice (pp. 50-65). Los Angeles: University of California Press.

Dilorio, C., Hartwell, T., & Hansen, N. (2002). Childhood sexual abuse and risk behaviors among men at high risk for HIV infection. American Journal of Public Health, 92(2), 214-219.

Drasin, H., Beals, K., Elliot, M., Lever, J., Klein, D, & Schuster, M. (2008). Age cohort differences in the developmental milestones of gay men. Journal of Homosexuality, 54(4), 381-399.

Duggan, S.J., & McCreary, D.R. (2004). Body image, eating disorders, and the drive for muscularity in gay and heterosexual men: The influence of media images. Journal of Homosexuality, 47(3/4), 45-58.

Duncan, D. (2007). Out of the closet and into the gym. The Journal of Men's Studies, 15(3), 331-346.

Falconer, J.W., & Neville, H.A. (2000). African American college women's body image: An examination of body mass, African self conscious, and skin colour satisfaction. Psychology of Women Quarterly, 24, 236-243.

Feldman, M.B., & Meyer, I.H. (2007a). Childhood abuse and eating disorders in gay and bisexual men. International Journal of Eating Disorders, 40(5), 418-423.

Feldman, M.B., & Meyer, I.H. (2007b). Eating disorders in diverse lesbian, gay, and bisexual populations. International Journal of Eating Disorders, 40(3), 218-226.

Gadalla, T., & Piran, N. (2007). Eating disorders and substance abuse in Canadian men and women: A national study. Eating Disorders, 15(3), 189-203.

Garner, D. (1997). The 1997 body image survey results. Psychology Today, 30, 30-44.

Garner, D., Olmstead, M., Bohr, Y., & Garfinkle, P. (1982). The eating attitude test: Psychometric features and clinical correlates. Psychological Medicine, 12, 871-878.

Garrow, J.S., & Webster, B.S. (1985). Quetelet's index (W/H) (2) as a measure of fatness. International Journal of Obesity, 9, 147-153.

Gentile, K., Raghavan, C., Rajah, V., & Gates, K. (2007). It doesn't happen here. Eating disorders in an ethnically diverse sample of economically disadvantaged, urban college students. Eating Disorders, 15(5), 405-425.

Gilman, S., Cochran, S., Mays, V., Hughes, M., Ostrow, D., & Kessler, R. (2001). Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the national comorbidity survey. American Journal of Public Health, 91(6), 933-939.

Goldfield, G.S., Blouin, A.G., & Woodside, D.B. (2006). Body image, binge eating, and bulimia nervosa in male body builders. Canadian Journal of Psychiatry, 51(3), 160-168.

Hartoum, I., & Belle, D. (2004). Mags and abs. Media consumption and bodily concerns in men. Sex Roles, 51, 397-407.

Harvey, J.A., & Robinson, J.D. (2003). Eating disorders in men: Current considerations. Journal of Clinical Psychology in Medical Settings, 10(4), 297-306.

Hospers, H.J., & Jansen, A., (2005). Why homosexuality is a risk factor for eating disorders. Psychology of Men and Masculinity, 8(1), 15-24.

Hudson, J.I., Hiripi, E., Pope, H.G., & Kessler, R.C. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61, 348-358.

Kaminski, P.L., Chapman, B.P., Haynes, S.D., & Own, L. (2005). Body image, eating behaviors, and attitudes toward exercise among gay and straight men. Eating Behaviors, 6(3), 179-187.

Kimmel, S.B., & Mahalik, J.R. (2005). Body image concerns of gay men: The roles of minority stress and conformity to masculine norms. Journal of Consulting and Clinical Psychology, 73(6), 1185-1190.

Kline, P. (1999). The handbook of psychological testing (2nd ed.). London: Routledge.

Kohout, F.J., Berkman, L.F., Evans, D.A., & Cornoni-Huntley, J. (1993). Two shorter forms of the CES-D (Center for Epidemiological Studies--Depression scale) depression symptoms index. Journal of Aging Health, 5, 179-193.

Kozak, M., Roberts, T., & Frankenhauser, H. (2009). Objects of desire: Objectification as a function of male sexual orientation. Psychology of Men and Masculinity, 10 (3), 225-230.

Kraft, C., Robinson, B., Nordstrom, D.L., Bockting, W.O., & Rosser, B.R.S. (2006). Obesity, body image, and unsafe sex in men who have sex with men. Archives of Sexual Behavior, 35(5), 587-595.

Levesque, M.J., & Vichesky, D.R. (2006). Raising the bar on the body beautiful: An analysis of the body image concerns of homosexual men. Body Image, 3(1), 45-55.

Martins, Y., Tiggermann, M., & Kirkbride, A. (2007). Those Speedos become them: The role of self-objectification in gay and heterosexual men's body image. Personality and Social Psychology Bulletin, 5, 634-647.

McCreary, D.R. (2007). The Drive for Muscularity Scale: Description, psychometrics, and research findings. In J.K. Thompson & G. Cafri (Eds.). The muscular ideal: Psychological, social, and medical perspectives (pp. 87-106). Washington, DC: American Psychological Association.

McCreary, D.R., & Sasse, D.K. (2000). An exploration of the drive for muscularity in adolescent boys and girls. Journal of American College Health, 48(6), 297-304.

Meyer, C., Blissett, J., & Oldfield, C. (2001). Sexual orientation and eating psychopathology: The role of masculinity and femininity. International Journal of Eating Disorders, 29(3), 314-318.

Meyer, I.H. (2003). Minority stress and mental health in gay men. In L.D. Garnets, & D.C. Kimmel (Eds.), Psychological perspectives on lesbian, gay, and bisexual experiences (2nd ed.) (pp. 699-731). New York: Columbia University Press.

Morgan, J., & Arcelus, J. (2009). Body image in gay and straight men: A qualitative study. European Eating Disorders Review, 7, 435-443.

Morrison, T., Morrison, M., & Hopkins, C. (2003), Striving for bodily perfection? An exploration of the drive for muscularity in Canadian men. Psychology of Men and Masculinity, 4, 111-120.

Mule, N.J. (2007) Sexual orientation discrimination in health care and social service policy: A comparative analysis of Canada, the UK and USA. In L. Badgett & J. Frank, (Eds). Sexual orientation discrimination: An international perspective (pp. 306-322). New York: Routledge.

National Center on Addiction and Substance Abuse (CASA) at Columbia University. (2003). Food for thought: Substance abuse and eating disorders New York, National Center on Addiction and Substance Abuse.

O'Dea, J.A., & Abraham, S. (2002). Disordered eating and exercise disorders in young college males. Journal of American College Health, 50(6), 273-278.

Picot, A.K. (2006). The relationship among community affiliation, self-esteem, and eating disorder symptomatology in gay and lesbian individuals. (Ph.D., Georgia State University). Dissertation Abstracts International: Section B: The Sciences and Engineering, 67(02). (3205408).

Pope, H., Phillips, K., & Olividari, R. (2000). The Adonis complex: The secret crisis of male body obsession. New York: The Free Press.

Pride Toronto. (2010, August 23). Retrieved from http://www.pridetoronto.com/festival/.

Ramsay, N., Catalan, J., & Gazzard, B. (1992). Eating disorders in men with HIV infection. British Journal of Psychiatry, 160, 404-407.

Ricciardelli, L.A., McCabe, M.P., Williams, R.J., & Thompson, J.K. (2007). The role of ethnicity and culture in body image and disordered eating among males. Clinical Psychology Review, 27(5), 582-606.

Russell, C.J., & Keel, P.K. (2002). Homosexuality as a specific risk factor for eating disorders in men. International Journal of Eating Disorders, 31(3), 300-306.

Savin-Williams, R. (2005). The new gay teenager. Cambridge, MA: Harvard University Press.

Siconolfi, D., Halkitis, P.N., Allomong, T.W., & Burton, C.L. (2009). Body dissatisfaction and eating disorders in a sample of gay and bisexual men. International Journal of Men's Health, 8(3), 254-264.

Siever, M.D. (1994). Sexual orientation and gender as factors in socioculturally acquired vulnerability to body dissatisfaction and eating disorders. Journal of Consulting and Clinical Psychology, 62(2), 252-260.

Siever, M.D. (1996). The perils of sexual objectification: Sexual orientation, gender, and socioculturally acquired vulnerability to body dissatisfaction and eating disorders. In C.J. Alexander (Ed.), Gay and lesbian mental health: A sourcebook for practitioners (pp. 223-247). Binghamton, NY: Harrington Park Press.

Smolak, L., & Murnen, S.K. (2002). A meta-analytic examination of the relationship between child sexual abuse and eating disorders. The International Journal of Eating Disorders, 31, 136-150.

Strong, S.M., Williamson, D.A., Netemeyer, R.G., & Geer, J.H. (2000). Eating disorder symptoms and concerns about body differ as a function of gender and sexual orientation. Journal of Social & Clinical Psychology, 19(2), 240-255.

Swami, V., & Tovee, M.J. (2008). The muscular male: A comparison of the physical attractiveness preferences of gay and heterosexual men. International Journal of Men's Health, 7(1), 59-71.

Swearingen, C.E. (2006). The role of internalized homophobia, sexual orientation concealment and social support in eating disorders and body image disturbances among lesbian, gay and bisexual individuals. (Ph.D., University of Oregon). Dissertation Abstracts International: Section B: The Sciences and Engineering, 67(10). (3238472)

Tjepkema, M. (2008). Health care use among gay, lesbian and bisexual Canadians. Statistics Canada Health Reports. Retrieved from http://www.statcan.gc.ca/pub/82-003-x/2008001/article/10532-eng.htm.

Torres, A.N. (2008). Internalized homophobia, self-esteem, gender roles, body image, and disordered eating in gay and bisexual men. Dissertation Abstracts International: Section B: The Sciences and Engineering, 68(11-B), 7680-7680.

Van Gerko, K., Hughes, M.L., Hamill. M., & Waller, G. (2005). Reported childhood sexual abuse and eating disordered cognitions and behaviours. Child Abuse Neglect, 29(4), 375-382.

Varas-Diaz, N., Alfonso-Toro, J., & Serrano-Garcia, I. (2005). My body, my stigma. Body image interpretation in a sample of people living with HIV/AIDS in Puerto Rico. Qualitative Health Report, 19, 122-142.

Weltzin, T.E., Weisensel, N., Franczyk, D., Burnett, K., Klitz, C., & Bean, P. (2005). Eating disorders in men: Update. Journal of Men's Health and Gender, 2(2), 186-191.

Wichstrom, L. (2006). Sexual orientation as a risk factor for bulimic symptoms. International Journal of Eating Disorders, 39(6), 448-453.

Williams, D., Neighbours, H., & Jackson, J. (2003). Racial/ethnic discrimination and health: Findings from community studies American Journal of Public Health, 93(2), 200-208.

Williamson, I. (1999). Why are gay men a high risk group for eating disturbance? European Eating Disorders Review, 7(1), 1-4.

Williamson, I., & Hartley, P. (1998). British research into the increased vulnerability of young gay men to eating disturbance and body dissatisfaction. European Eating Disorders Review, 6(3), 160-170.

Wilton, L. (2009). A preliminary study of body image and HIV sexual risk behavior in black gay and bisexual men: Implications for HIV prevention. Journal of Gay and Lesbian Social Services, 21(4), 309-325.

Woodside, D.B., Garfinkel, P.E., Lin, E., Goefing, P., Kaplan, A.S., Goldbloom, D.S., & Kennedy, S.H. (2001). Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. American Journal of Psychiatry, 158(4), 570-574.

Yaeger, J. (2000). Weighty perspectives: Contemporary challenges in obesity and eating disorders. American Journal of Psychiatry, 151, 851-853.

Yelland, C., & Tiggemann, M. (2003). Muscularity and the gay ideal: Body dissatisfaction and disordered eating in homosexual men. Eating Behaviors, 4(2), 107-116.

MA, MRE, PND (CAND), TREVOR A. HART (2), PHD, TAHANY GADALLA (1), MMATH, MSC, PHD, AND LORALEE GILLIS (3), BA

(1) Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON.

(2) Department of Psychology, Ryerson University, Toronto, ON.

(3) Rainbow Health Ontario, Toronto, ON.

The authors wish to acknowledge that funding for this project came from the Ontario HIV Treatment Network and The Society for the Psychological Study of Social Issues of the American Psychological Association. Additionally, the authors are grateful to Rainbow Health Ontario, Winston Husbands and the staff at the AIDS Committee of Toronto as well as the more than 30 volunteers who assisted with recruitment. Finally, we are especially thankful to the study participants.

Correspondence concerning this article should be sent to David J. Brennan, Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, Canada M5S 1V4. Email: david.brennan@utoronto.ca
Table 1
Demographic Characteristics of Participants (N = 383)

Characteristic                                       n       %

Age at time of survey (years)
  16-25                                              121     31.6
  26-30                                               68     17.8
  31-40                                               72     18.8
  41-50                                               86     22.5
  51+                                                 36      9.4

Race/Ethnicity
  White                                              228     59.6
  Black/African/Caribbean                             53     13.8
  Asian                                               75     19.6
  Other                                               27      7.0

Education
  High school diploma or less                         67     17.5
  At least some College or University                316     82.5

Relationship Status
  Single                                             208     54.3
  A relationship for less than six months             28      7.3
  > Six months and monogamous                         72     18.8
  A non-monogamous relationship for > six months      75     19.6

HIV Status
  HIV Negative                                       305     79.6
  HIV Positive                                        52     13.6
  Unknown                                             26      6.8

Childhood Sexual Abuse
  No                                                 258     67.4
  Yes                                                125     32.6

Sero-Discordant Intercourse Primary/Secondary
  No risk                                            301    978.6
  Risk                                                82     21.4

Disordered Eating Risk
  No risk                                            331     86.4
  Risk                                                52     13.6

Table 2
Binary Logistic Regressions: Correlates of Disordered Eating Risk
(n = 383)

Variable                           B      SE       OR        95% Cl

Age
  16-24 (ref.)                    --      --       --          --
  25-29                          -0.51   0.46   0.60       0.24, 1.49
  30-39                          -1.41   0.56   0.25 *     0.08, 0.73
  40-49                          -0.84   0.45   0.43       0.18, 1.04
  50+                            -2.20   1.10   0.11 *     0.01, 0.96

Race
  White (ref.)                    --      --       --          --
  Black                          -1.34   0.59   0.26 *     0.08, 0.83
  East and South Asian           -1.26   0.51   0.28 *     0.10, 0.77
  Other/Mixed Race/
    Aboriginal/Arab/Latino       -1.14   0.72   0.32       0.08, 1.31

Childhood Sexual Abuse            0.77   0.35   2.16 *     1.09, 4.27

Alcohol Use During Sex
  None (ref.)                     --      --       --          --
  Moderate                       -0.44   0.40   0.64       0.29, 1.41
  High                            0.80   0.48   2.22       0.87, 5.67

Propensity for Depression         0.08   0.04   1.08 *     1.01, 1.16

Behavioural Muscularity
  Behavioural Muscularity 1
    (ref.)                        --      --       --          --
  Behavioural Muscularity 2       1.29   0.54   3.62 *     1.26, 10.40
  Behavioural Muscularity 3       0.80   0.54   2.22       0.77, 6.37
  Behavioural Muscularity 4       2.10   0.50   8.14 ***   3.03, 21.87

Note. ref. = referent group; C1= confidence interval for odds ratio
(OR). The model accounts for 14.7% to 26.7% of the variance.

* p<.05. *** p<.001.
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