Social support in a men's online eating disorder forum.
Article Type: Report
Subject: Social networks (Research)
Eating disorders (Care and treatment)
Eating disorders (Social aspects)
Electronic discussion groups (Usage)
Men (Health aspects)
Men (Research)
Authors: Flynn, Mark A.
Stana, Alexandru
Pub Date: 06/22/2012
Publication: Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Men's Studies Press ISSN: 1532-6306
Issue: Date: Summer, 2012 Source Volume: 11 Source Issue: 2
Topic: Event Code: 310 Science & research; 290 Public affairs Computer Subject: Internet newsgroup
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 305192592
Full Text: Recent research has shown social support to be a useful theoretical framework when investigating women's online eating disorder forums. We sought to identify the types of social support present and the various functions each serve for members of a men's online forum. To answer the research questions, we conducted a deductive thematic analysis of 358 posts by 89 members of a UK-based men's eating disorder forum. Consistent with past research on women's forums, the most common types of support were informational, emotional and personal disclosure. In addition, advice emerged as a unique and prominent category of social support. Five broad themes of social support are also discussed and implications for future research using the social support framework were provided.

Keywords: social support, online forum, eating disorder, qualitative research, men's health

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Research on the effects of sociocultural factors such as parents, peers and media has consistently shown that boys and men may develop eating disorders as they attempt to meet an unrealistic body ideal (Harrison, 2001, Levine & Harrison, 2009; Pope et al., 2000). Brumberg's (1988) comments, while specifically addressing women, ring true for men as well: "More often than not, those who strive for physical perfection are concerned about what they eat" (p. 558). Smolak, Murnen, and Thompson (2005) also note that the ideal male body type, which has become increasingly more muscular, has led to body dissatisfaction prompting men to eat in unhealthy ways. Indeed, content analyses show that the male body ideal has become increasingly more muscular and lean over the past several decades (Law & Labre, 2002; Labre, 2005; Leit, Pope, & Gray 2001; Pope et al., 1999; Frederick et al., 2005). Also, the number of men diagnosed with eating disorders has grown to alarming rates over the past few years, with many more going unreported. According to Weltzin (2010) of the National Association of Anorexia Nervosa and Associated Disorders (ANAD), anorexia and bulimia are said to affect over 5 million Americans each year, with men making up 25 percent. Further, according to Levine and Harrison (2009) there is now a 3:2 ratio between women/men with binge eating behavior.

While the numbers of men with eating disorders have reached significance, eating disorders are traditionally viewed as a female problem (Andersen, 1990; Eliot & Baker, 2001). Such a misperception has damaging effects on men with eating disorders (Eliot & Baker, 2001). Today's Western culture is one where men are conditioned to hide potential eating problems because revealing a disorder is viewed as feminine by society (Bordo, 1999). Indeed, research suggests men are less likely than women to seek help (ANAD, 2011; Andersen, 1990). Consequently, a significant number of those with eating disorders go undiagnosed (Weltzin, 2010). Under-diagnosis is especially true in young boys--doctors are simply not looking for eating disorders in boys as much as in girls (Andersen, 1990; Weltzin, 2010). Therefore, many more men than reported may have eating disorders and even those who are diagnosed may not be receiving treatment until later in life.

The increased media focus on body ideals and the growing numbers of eating disorder diagnoses has led scholars to investigate eating disorder support groups, specifically online support groups. One rationale for the study of online support groups is the potential benefit received by their members. In a study of women with eating disorders, Walstrom (2000) found that online support groups are a useful alternative to face-to-face support groups. Goffman, (1967) in his discussion of "face" posits that we may avoid interaction when there is potential for embarrassment or humiliation. Online discussion boards present a venue to minimize such fears (Walstrom, 2000). Because information about eating disorders affecting men may not be readily and immediately available to those affected, men could turn to such online forums to receive preliminary information, guidance, and support from other men living with eating disorders. Also. since men are less likely to discuss potential eating disorders with friends, family or doctors, the relatively anonymous communication in an online environment may be the only help many men receive. In addition, such online forums can be accessed 24-hours-a-day, unlike traditional, face-to-face services, which only have limited work hours.

Online support groups for individuals with eating disorders have grown in number over the past fifteen years, and were even reported to be a common internet phenomenon as early as 1995 (Winzelberg, 1997). The study of such groups using a social support theoretical framework has also grown in recent years, though it still remains a relatively small research topic in academic literature (Keshi-Rahkonen & Tozzi, 2005; McCormack & Coulson, 2009; Ransom et al., 2010; Walstrom, 2000; Wesemann & Grunwald, 2008: Winzelberg, 1997). Studies that do address eating disorder forums devote their efforts to discussion boards primarily used by women, which comes as no surprise since most internet forums dedicated to eating disorders cater to female members. However, in recent years eating disorder forums for men have increased in number. Nonetheless, no study to date has addressed forums specifically developed for men. In addition, past research on eating disorder forums has shown social support to be a useful theoretical framework, but research guided by this framework has not been conducted in the context of men's forums. The present study is an attempt to address these issues.

SOCIAL SUPPORT IN ONLINE GROUPS

Social support constitutes a theoretical framework that can help recognize and explain the dynamics and interactions that take place within online support groups. Aside from its explanatory power, a social support approach could provide powerful techniques for the prevention and amelioration of psychological problems like stress, anxiety, or depression (LaRocco, House, & French. 1980). Thus, studying online support groups from a social support perspective is an important communication and psychological direction of research.

The study of social support can be traced back to the pioneering work of Emile Durkheim, who investigated the dissolution of clear social norms and roles. Subsequent research revealed that some requirements for psychological well-being can only be reached through social relationships. Weiss (1977, in Vaux, 1988) discusses some of these provisions, the most important being social integration and guidance. Social integration is provided by a network of people that share concerns, and involves common interpretation of experience, companionship, and opportunities for reciprocal services. The second provision, guidance, becomes of utmost importance in stressful situations, and it consists of emotional support and problem-solving guidance derived from relationships with persons who are trusted and respected. Guidance is especially relevant with respect to the topic of online support groups for men with eating disorders--a population that perhaps needs more advice and support than others from trusted and respected sources because of the societal stigma and pressures associated with this affliction.

More recently, social support has been studied as a communication phenomenon. Since social support occurs via messages directed by one individual to another in the context of a relationship that is created and maintained via interaction, it is clear that social support cannot be detached from communication (Burleson, Albrecht, Goldsmith, & Sarason, 1994). From this perspective, social support has been defined as "the exchange of verbal and nonverbal messages conveying emotion, information, or referral, to help reduce one's uncertainty or stress" (Walther & Boyd, 2002, p. 154). Communication scholars have studied social support from the perspective of messages through which people seek and offer support, the interactions in which supportive messages are generated, and the relationships that are created by and contextualize the supportive interactions (idem). Yet, as communication research is still at a relatively early stage in the exploration of social support contexts, it is unclear how the comforting messages through which social support occurs affect the emotional states of others (Burleson et al.. 1994). It is therefore important that more focused research is conducted to uncover the mechanisms that underlie social support. Aside for an unquestionably important theoretical advance, such findings could also have very clear practical implications. For example, a clearer understanding of social support mechanisms could help medical professionals tailor more effective messages and create supportive environments-both online and offline--that would better meet the needs of individuals diagnosed with various disorders. In spite of the aforementioned theoretical difficulties, there is little doubt that information about one person's stressful life event, be it related to illness, addictions, mental health issues, loss/bereavement, financial difficulties, can enable another person to use his/her own coping mechanisms more effectively to help reduce stress and to allow for a more accurate evaluation of the stressful event (Peterson, 2009).

With the advent of technology and computer-mediated support groups, which provide an alternative to face-to-face groups, social support researchers have redirected their attention to the unique characteristics of these mediated groups. For example, investigations of online support groups for individuals dealing with personal loss, bereavement, and eating disorders have been conducted (McCormack & Coulson, 2010; Van Der Houwen, Stroebe, Schut, Stroebe, & Van Den Bout, 2010). So far, research suggests that the same social support resources that characterize face-to-face groups are also present in online social support groups (Peterson, 2009). However, while there seems to be agreement about the benefits of social support sought and offered in the online environment, certain questions remain unanswered. Currently, little is known about the mechanisms through which social support occur in online groups. Also, the themes and patterns that permeate communication acts in online support groups received some, but perhaps not sufficient, attention.

In addition, research has shown that not all support groups are created equal. Studies have found that social support is more useful and more sought by individuals living with illnesses and medical conditions that are stigmatized by societal norms. For instance, HIV/AIDS patients are 250 times more likely to belong to a support group than patients with arterial hypertension (Davidson, Pennebaker, & Dickerson, 2000). At the same time, research suggests that not all online groups function similarly or have similar structures and goals. For example, Peterson (2009), in a study of an online support group for gay men diagnosed with HIV/AIDS, found that the group's main goal was to maintain a positive and optimistic atmosphere among group members. The group has negotiated the process of positive social support as a core group value. Group membership served as a buffer for the stress generated by being diagnosed with HIV/AIDS. Other studies, however, concluded that in certain circumstances, being a member of a support group can have both positive and negative outcomes. For example, Keski-Rakhonnen & Tozzi (2005) found that for individuals with eating disorders participation in internet discussion groups was beneficial in the initial stages of recovery, but detrimental to recovery in the last stages. This, and other similar findings suggest that enthusiastic proposals that traditional face-to-face support and counseling be completely replaced by online support in the foreseeable future should be met with caution.

MEN, MASCULINITY, AND HELP-SEEKING ONLINE

It has become increasingly accepted, in the social sciences, humanities, and medical field alike, that men frequently delay seeking help for a variety of health issues (Brown & Bond, 2008). In turn, this tendency may impair men's general well-being and could contribute to their lower life expectancy compared to women (idem). One salient factor that may contribute to this tendency is masculinity, defined by society's expectations of men to display characteristics such as invincibility, toughness, and stoicism (Bordo, 1999: White & Johnson, 2000). Research in health behavior has found that men are more likely to seek medical attention for substantial events such as bleeding wounds, broken bones, or joint dislocation, because seeking help for such traumas does not endanger their masculinity (Sobralske, 2006). However. less "masculine" traumas and conditions, such as mental health-related issues, tend to be ignored or downplayed, in order to conceal vulnerability (Brown & Bond, 2008" Fletcher & St. George, 2010; George & Fleming, 2004).

Indeed, help-seeking research has largely found gender norms to influence communication (Courtney. 2000" Gray et al., 1996; Mo, Malik, & Coulson, 2009; Sullivan, 2003). While feminine norms stress emotional expression and nurturing behavior for women, masculine norms stress emotional restraint and self-reliance in men (Reddin & Sonn, 2003; Seale, 2006). In a recent review of literature on help seeking online. Mo, Malik, and Coulson (2009) found that, in line with western societies' expectations of gendered behavior, men tend to provide greater information on discussion forums while women tend to share more emotion. Such findings have been particularly evident in analyses of cancer support groups (prostate and breast cancer) (Mo, Malik, & Coulson; Sullivan, 2003). Although recently some scholars have questioned the impact of masculinity on men's help seeking behavior online (see Fletcher & St. George, 2010; Brown & Bond, 2008), the overwhelming body of literature suggests it is, at the very least, an important variable. The current analysis of a male eating disorder forum will serve to further investigate the power of gender norms in an online help-seeking context.

In summary, online support groups for individuals with "niche" conditions, such as men with eating disorders, have not been systematically investigated. Furthermore, the role of gender norms in the social support process in such groups has yet to be examined. Based on the discussion of social support and men's help seeking, and the lack of research attention in this area, several research questions were used to guide our inquiry:

RQI: What are the specific types of social support messages used by men on an online eating disorder forum?

RQ2: What functions do these messages serve for male members of online eating disorder forums?

RQ3: Are the messages exchanged in line with traditional gender norms?

METHODS

Data Collection

In this study, we examined the themes that pervaded communication acts on a public online forum dedicated to men with eating disorders. Informed by previous research, we employed the following criteria to select an online group for analysis: a) the forum had to be open (no membership and/or monetary fee were required of participants); and b) the group had to be sufficiently active in terms of number of active members, number of views, and of number of messages posted (McCormack & Coulson, 2009). Following these criteria, we selected a group that will remain nameless to ensure the anonymity of the forum members.

Since no formal guideline about a sufficient number of messages necessary for such a thematic analysis exists, we continued to download and analyze messages until thematic saturation was reached (Glaser & Strauss, 1967; McCormack & Coulson, 2009). We selected and analyzed 358 messages (posts) grouped in the 27 most popular threads on the forum. In deciding which threads were "the most popular", we took into consideration not only the total number of messages posted on a thread, but also the number of views. "Lurkers" (participants who read the messages but do not contribute to the forum) are an important group on online health-related forums, with some studies mentioning an average of 45.5 percent of lurkers on such groups (Nonneke & Preece, 2001, in van Uden-Kraan et al., 2008). Although lurking has sometimes been seen as negative behavior--lurkers being described as 'tree-riders' who use the resources of the community but fail to give back (Smith & Kollock, 1999)--more recent research has shown that participation in online support groups has similar effects for active as well as passive members. Lurkers self-reported similar levels of empowerment as members who actively participated in health-related support groups. Simply reading messages seems sufficient to benefit from participation in an online support group (van Uden-Kraan et al., 2008), which is why total views as well as posts were important to consider during the data collection process.

Forum Members

A total of 89 different members contributed posts to the 27 examined threads. Of those members, 17 were women. The women who posted did so rarely, totaling a very small number of the total posts examined. The female presence may be explained by the structure of the site. The male eating disorder forum chosen for this investigation is part of a larger site that also includes a female eating disorder forum. The age, ethnicity and education levels of participants were unknown. However. the location of each discussion board member was noted next to each post. Although the forum was created in the UK, members varied in their location, coming from the UK, United States, Canada, New Zealand and Australia. In all, 43 of the 89 members explicitly disclosed having some form of eating disorder. Nineteen members disclosed that they had seen doctors for their disorder (some members acknowledged going regularly), and two members disclosed a period of hospitalization at a mental health facility. Finally, a female forum member with anorexia noted that she was a former bodybuilder, and 15 other male members with anorexia discussed their propensity for over-exercising.

Data Analysis

Message content was analyzed thematically in three stages of coding: open, axial, and selective (Glaser & Strauss, 1967; Strauss & Corbin, 1990). Both authors participated in all stages of coding. First, we used open coding to evaluate the data. Open coding involves breaking down raw messages into individual units that convey a single idea (Strauss & Corbin, 1990). Some units were single sentences, others entire paragraphs. For the open coding, both authors first jointly analyzed roughly 20 percent of the raw data together to establish consistency. From that point on we separated the remaining data into two parts for each author to analyze independently. The open coding resulted in 1372 distinct idea units from the original 358 posts.

We then used the axial coding process to further breakdown the 1372 idea units. Axial coding involves the creation of categories, around which the data are grouped together based on similar themes (Corbin & Strauss, 1990; Strauss & Corbin, 1990). Previous research on social support was used to guide the axial coding process. The purpose of the axial coding in this analysis was to determine the form social support takes in this specific setting and the frequency with which these forms of social support occur. In order to address these issues, we sought to integrate social support theoretical precepts with categories emerging from the data. The categories we created, which are discussed in further detail below, pertain to the manner in which social support occurs and has been conceptualized in a communication context. For example, we sought to monitor the messages through which social support occurs, as well as the context in which these messages were conveyed. Two studies in particular were instrumental in providing a theoretical framework for use during the axial coding process (McCormick & Coulson, 2009; Winzelberg, 1997). Both studies used the social support framework in their analysis of online support groups for women with eating disorders. When devising our coding book, we were informed by coding schemes from both of these studies. Both had similar coding schemes, with many overlapping types of social support. We sought to find out which categories were most prominent and what (if any) new categories emerged during data analysis. As previous research notes, the thematic analysis framework, in the form employed here, is useful not only for discovering new theory but also for reexamining existing frameworks (Smith & Krugman, 2010; Burawoy, 1991; Strauss & Corbin, 1994). Therefore, we decided to use an existing social support framework for this examination. This decision was primarily made because of the close relationship between the current analysis and the previously discussed works--all investigate social support in online eating disorder forums. The final coding process involved selective coding. This process was used to explicate the axial categories into broad conceptual themes for discussion.

RESULTS

Social Support Categories

After the individual idea units were created through open coding, axial coding was employed to further categorize the data. As previously mentioned, a coding scheme based on a combination of existing research on social support was used during the axial coding process (McCormick & Coulson, 2010; Winzelberg, 1997). Many of the categories present were in line with past research on social support in eating disorder forums including: requesting personal disclosure, providing personal disclosure, requesting emotional support, providing emotional support, providing information, seeking information, providing emotional expression, requesting emotional expression, displaying gratitude, and board maintenance. In addition to these existing categories, two new categories were present: seeking and receiving advice. Table 1 describes the axial categories with a brief example of each. The current analysis revealed some categories to be more salient than others in the male eating disorder forum than in previously researched female eating disorders forums. As Table 2 shows, providing personal disclosure was the most common message category (33.8%), followed by providing emotional support (23.1%). Conversely, forum members rarely requested advice (0.4%), requested emotional expression (0.3%), or discussed board maintenance (0.8%). Each category will be discussed further to highlight examples and patterns present in each.

Personal disclosure. The most common type of social support found was personal disclosure (37.6%), with most members providing disclosures (33.8%). Types of disclosures varied, but some common types were: members' descriptions of experiences with their eating disorders (symptoms, habits, etc.), admissions of having an eating disorder, intent to seek (or admission of seeking) professional help, and sharing of feelings. As seen here, providing disclosure can be received as social support in several ways. First, the person disclosing can receive social support through feedback. Such support was a consistent presence throughout the posts. Second, those empathizing with the discloser of personal information may realize social support by sharing their emotional experiences with someone who knows and understands the same feelings. Indeed many displayed their empathy through replies to the discloser. However, many other men may have also benefited from emotional support by reading the comments made by others. As previously noted, forum views far outnumbered posts--358 posts were made on the 27 examined threads, whereas the same threads were viewed over 22,000 times. While the argument can be made that some of the 89 members viewed the threads many times, there is still the likely possibility that many additional men viewed the forum content, thus increasing the social support received through self-disclosures. An example of a commonly displayed form of self-disclosure is useful to illustrate the themes highlighted. The usernames have been removed in an attempt to ensure the anonymity of the participants. The examples provided here retain the original form in which they were published on the forum, including typographical, grammatical, or spelling errors.

Example (Initial Post):

I am a ******** year old in highschool [sic'] and recently I had some blood work done because lor the past year I have been feeling the following symptoms: Fatigue, weakness, constant hunger, cold body temperature, and overall lack of energy in everything I used to do. The blood work came back with extremely low tesosterone [sic], and I'm not sure on other suppression. What triggered all of this happened a year ago in the summer of

Starting the summer around June I weighed ************ lbs and just got done competing at state wrestling. When that was over I decided to cut down for next year right away to have a better chance at doing better in wrestling. I started eating less and less, and eventually lost ******** pounds. All of this ended around September, so from June-September around four months I had pretty much developed an eating disorder from my favorite sport. Before this I was at a healthy weight and develping [sic] normally.

I have seen two endocrinologists in Iowa both of them telling me to check mayo clinic because they are the best at handling these problems.

Has anyone heard of any males having problems with testosterone levels after this and how did they get them up?

Reply:

Hey XXXX.

In high school I experienced what you described. To be honest, not sure what long term effects the low T levels had. Once I regained I never had that many labs done and in my later episodes I did not have T tested. I do know that I never really developed a "manly" body type (shoulder spread and bulkier frame) until starting about late twenties approx. five years after my last major episode of restriction. Previous to this change I simply kept my teen boy almost androgynous body type of tall, lean with small bone stucture [sic]. Comparing myself with my brother and father, I am considerably more feminine in appearance and much less muscling and body hair. I am not able to "bulk up" like them and even with proper diet and excercise [sic] do not get pumped up.

Emotional support. The second most frequent type of support, emotional, comprised 26.4 percent of all message units. However, as with personal disclosure, providing was much more common than seeking support. Some common sub-categories present in messages providing emotional support were empathy, sympathy, agreement and encouragement. We defined these concepts after they emerged in the initial coding process. Another round of coding then ensued to separate emotionally supportive messages into the following four categories. Empathy was seen as comments made to relate to another forum member on an emotional level based on shared experiences; Sympathy as emotional support was viewed as comments that showed understanding of another's emotional struggles; Agreement was seen as concurrence with another forum member's ideas, attitudes or beliefs; and Encouragement was seen as comments used to propel other forum members to keep making progress, congratulations for progress made, or to seek initial/continued help. Other less common, but still present forms of emotional support, were humor and prayer. Below are excerpts from an initial post and two replies that demonstrate encouragement (reply 1) and sympathy (reply 2).

Example (Initial Post):

Hi,

I don't quite know where to start so please bear with me. I have a feeling i might be suffering from Anorexia or a similar condition which until recently i was perhaps unaware of. I have done some basic research online and also looked back at what my dieting habits have been like for the last few years and it is only now i am seeing what has been happening.

I tend to avoid social outings but when I do go out I will eat if food is being provided, like lunch or a bbq [sic] etc. [B]ut I will keep tabs on what I have had and then offset it by reducing or omiting [sic] meals later that day and for the next few days after it. I just don't quite know what to do

Kind regards, XXXX

Reply 1:

Certainly keep sharing here as we need to get out the issues inside of us which are behind all of this. god bless.

Reply 2:

Dear XXXX, It's brave of you to share your story. Just know, that for whatever it's worth, you have our support. You definitely aren't alone! Best, XXXX

Informational support. Informational support accounted for 11.1 percent of all message units. However, providing was much more common than seeking information. Those providing information typically gave details about eating disorders such as facts, symptoms, effects, and common struggles experienced by those with an eating disorder. In one example, a member used factual information about medical terminology in his response on a thread discussing "Manorexia" to support the member initiating the thread.

Example (Initial Post): Is anyone else completely offended by the term [Manorexia]? Personally I feel like it's putting down the significance of a disease because 'real men aren't supposed to care' or some sort of warped logic like that. [W]anted to hear some feedback

Reply:

I've just recently started to wonder why people don't refer to the disorders as AN (Anorexia Nervosa), BN (Bulimia Nervosa), and BED (Binge Eating Disorder). It's common to do this to so many other illnesses with unwieldy Latin or Greek names, yet these diseases are just "Anorexia" (which is technically not correct because that's the official medical term for normal physical loss of appetite) and "Bulimia."

Research has shown that when you use the proper medical term for a condition, it gets better attention and is considered more serious. Such is the case with erectile dysfunction, formerly called "impotence." The latter term was stigmatized and implied that this meant something was wrong with the man or he had done something wrong. The new term says that this is a medical condition that he can't help, and so he can get proper treatment.

Providing information also included content discussing the benefits of seeking professional help, and the common media portrayals of men with eating disorders. Seeking information, though much less common, did occur. Informational probes addressed specific disorder-related or science-related questions. For example, when discussing the effects of his eating disorder on testosterone levels and how that may differ from others' testosterone levels, one forum member asks: "'what, on a cellular level, is it that causes the different reaction?" This particular informational probe did not get a specific response. The presence of technical information probes, most of which only answerable by a qualified professional, show that many forum members may not be getting the clinical help needed for their disorders. The common appearance of such posts may be due to the cultural stigma against men revealing an eating disorder, as well as the propensity for men to be under-diagnosed.

Advice. One of the most important forms of support, offering (0.4%) and seeking (9.3%) advice, constitutes 9.7 percent of the messages posted on the board. Research has shown that advice can be a vital form of social support in a time of heightened stress (Peterson, 2009). Advice can take the form of prompting members of the forum to take action in order to limit or stop the effects of eating disorders (e.g., seek medical attention, avoid certain destructive practices and behaviors) or encouraging them to find psychological support by joining the forum, not leaving the forum and/or by finding emotional support in the offline world. An example illustrates impact that advice provided on the forum:

Example 1:

Hi XXXX,

I strongly urge you to speak about this and as soon as possible. Anorexia is not something to be messed around with and you don't know when something very serious will happen. You need to do this. You deserve the proper help and care.

If you cannot bring yourself to discuss it what about printing off your original post or writing something down and handing it to the dr?

Good luck

Reply:

Thanks again guys, I have confided with my boss at work today because I wanted to get a second opinion on whether I really have a problem or whether I just perceive that I do. He has assured me that from what he has seen and heard I definitely do have a problem. He is also encouraging me to see a doctor and has offered me free use of any services that work can provide. I have also made a doctors [sic] appointment for this week, the boss is coming along with me if possible for moral support. He agrees that perhaps I don't fully realise [sic] the seriousness of the situation that I am in, and understands my aprehension [sic] at raising my hand and asking for help. I will let you guys know how it went after the appointment,

Another example of advice is also useful to display the give and take dynamics of social support among forum members. Members do not just receive support, but those who are struggling with their eating disorders are also able to lend support. The forum member who wrote the initial post in the above example was able to provide support to another member who was also struggling with his eating disorder. In the following example, the individual who called out for extended help in the initial post above is now providing advice to a fellow forum member.

Example 2:

Hi XXXX,

I am saddened to see that your [sic] still struggling with your inner demons whilst still waiting for the proper help you so desperately need. Please listen to XXXX as he has been through this before and can offer you some advice to help get through this rough period until you can get professional help. He has helped me out a lot [sic] already although at the moment i seem to he taking a backward step.

Emotional expression. Emotional expression was present in 9.4 percent of the messages posted on the forum. Most of the messages in this category were providing emotional expression (9.1%), whereas requesting was present in only four messages. Emotionally expressive posts seemed to serve a cathartic function, many of these messages being categorized by the posters themselves as "venting". Further, emotionally expressive messages allowed posters to articulate their feelings about their eating disorder and its impact on their personal, familial, social, or professional lives. These messages were overwhelmingly negative, posters alluding to "nasty shocks," "'despair," and situations that "drive [them] crazy."

Example 1:

All of this just stems from ignorance. People think they know eating disorders (It's just about food and weight, they're vain, selfish, etc.), so they make sweeping assumptions about them. Sorry, this rant has been percolating in my head for weeks and I've finally had a chance to let it out.

Occasionally, members express their hope that they will receive help in the form of social support from the other members of the forum. Other members supported this form of emotional expression.

Example 2 (Initial Post):

I will keep posting here as there are times where i feel i just need to let 'someone' know that everything is not alright.

Reply:

I'm glad you found a safe place to vent--please post as often as you feel is necessary.

Gratitude. Showing gratitude for the advice and support received from other members of the group comprised 5 percent of all examined posts. These messages showed appreciation for listening, encouragement, support, information, and advice. Members also thanked the others for providing them with a safe place where they could express their frustration and anxiety. This allowed participants to show their appreciation to others for reading and replying to their messages. Gratitude messages are sometimes general and addressed to the entire group, like: "Thanks guys for your continuing support," but they were also addressed to specific members who were more active in offering advice and support: "Thanks XXXXX and YYYYY. You hit the nail on the head on the head with all the symptoms showing but yet the medical profession fails to fully put the pieces together."

Social Support Themes

After data went through open and axial coding, selective coding revealed five overarching themes: direct/indirect support; online/offline support; providing/seeking content; the impact of masculinity norms; and creating a positive culture.

Theme 1: Direct and indirect support. Consistent with past research on female eating disorder forums (McCormack & Coulson, 2009; Winzelberg, 1997), we found both direct and indirect support in a male forum. Men both sought and received direct support by asking for help and receiving direct feedback from other forum members. Such support came in the form of personal disclosure, information, emotional support, and advice. Lacking in previous research was a distinct advice category. Many forum members willingly gave advice to other members based on their own experiences. It is not known how effective such advice can be, but as the results show, some members were moved to seek treatment as a result of advice from other members.

Indirect support to initial pleas for help was received through the emotional expression of other members. Emotional expression may not have been intentionally sent to another member as support, but by sharing similar thoughts, support was indirectly provided. Also, the many potential lurkers who read but did not post may have received indirect support. These men may have lacked the efficacy of the members who posted, but were still able to realize support indirectly in their role as "invisible watchers". Support gained by lurkers could be an important benefit of online support groups. It would be impossible for these individuals to obtain such support in an offline setting.

Theme 2: Online/offline support. One interesting finding was that members either came to the forum first, then sought offline support later from friends, support groups, and/or trained professionals; or vice versa. Both phenomena show that support online does not replace support offline. Rather, many of the men in this forum used the two contexts together to gain support for their eating disorder. Perhaps more important for men though is seeking help offline after coming to the forum. Since men are less likely to seek support overall, visiting the forum first may help ease them into requesting face-to-face support later. Our investigation found this to be true with one individual, but broader implications for the usefulness of online forums for men with eating disorders are certainly possible. As past research suggests, eating disorder forums have the ability to work in tandem with offline support networks such as parents, friends, romantic partners, and health professionals (Ransom et al., 2010).

Theme 3: Providing/seeking content. In line with previous research (McCormack & Coulson, 2009; Winzelberg, 1997), most messages provided support either through emotions, information or personal disclosure. Much less frequent was seeking such support. This was most likely the case because when one forum member would ask for emotional support, information, or personal disclosure, many other forum members responded to their plea. It is also possible that individuals are more comfortable sharing rather than seeking support for reasons of presenting a strong "face" (Goffman, 1967). Walstrom (2000), in her analysis of online eating disorder support groups says that there is "potential risk at stake in all interaction for being embarrassed or humiliated when our wants are not observed" (p. 764). Hackler, Vogel, and Wade (2010), also suggest that that the anticipated risks of seeking help impact whether support is sought. Such risks may be lower when providing support than asking for it.

Theme 4: The impact (or lack thereof) of masculinity norms. Contrary to previous research on social support and help seeking, men in the forum examined here used personal disclosure and emotional support more often than any other type of support. In fact, when combined these types of support accounted for over 60 percent of all messages. Informational support, which was consistently found to be the highest form of support used by men in past research (Sullivan, 2003; Blank et al., 2010; Mo et al., 2009), accounted for only 11.1 percent of messages. On face value, the findings seem to reject the influence of masculinity norms on the behavior of men with eating disorders in the examined forum. However, the perceived social sanctions that prevent many men from sharing their eating disorders offline may be help explain the findings here. Further discussion of this finding is warranted.

Theme 5: Creating a positive culture. Many online support groups are designed to maintain a positive atmosphere as an essential condition to provide members with adequate support and help (Peterson, 2009), and the forum examined here is no exception. The administrators of the forum created a set of rules in an attempt to prohibit any sort of behavior that could trigger or strengthen an eating disorder among the active or passive members of the forum. For example, participants are asked to refrain from using numbers in their posts (in reference to weight, clothing size, BMI, calories), 'tips' or 'bragging' that might encourage others to develop or hide an eating disorder, suicide notes, or links to websites that promote eating disorders. These guidelines are generally reflected in the messages posted on the men's eating disorders forum. In the few instances in which posters inserted numbers in their messages, these were censored. Although many posts express negative emotions, they rarely, if ever, convey desperation; rather, they express frustration with the consequences of living with an eating disorder, and they are met with messages of support, positive advice, and encouragement, illustrated in this example: "Hi XXXX, happy to share things with you if it is of any help, nice to get something positive out of a real negative."

DISCUSSION

Within the direct/indirect support theme, advice emerged as a unique type of social support seldom addressed as a specific category in previous research. Its presence in the forum was fairly prominent, accounting for about 10 percent of all idea units. We believe this is an important finding and should be explored further in future research endeavors. Specifically, how often is advice heeded in eating disorder forums, how beneficial is the advice given, and how does this compare to the advice provided by offline support systems? More focused methods, such as in-depth interviews, may be a necessary next step to further explore the importance of advice as social support among eating disorder support group members.

Along with forms of support received by active participants in the forum, indirect support may be gained by lurkers. This finding is of crucial importance for men with eating disorders and has implications for the dynamics of how men seek social support. As noted in the introduction, online forums may help combat the societal stigma that prevents many men from revealing an eating disorder and seeking support. Even those who did not participate in the forum may still benefit from the types of support discussed here through their role as lurkers. Moreover, repeated exposure to supportive messages from other men with eating disorders may serve to combat the current cultural stigma and eventually lead some lurkers to become posters. Indeed, the results demonstrate that such a phenomenon occurs--longtime members but first time posters started a number of the examined threads.

The second theme, online/offline support, is also worthy of further discussion. Receiving support in the offline world requires certain resources (access to medical care, insurance coverage, money for co-pays, etc.), which are not necessary in the case of obtaining support in the online world. In addition, online support can be accessed via online forums 24/7, unlike face-to-face services, which have restricted opening hours. This makes the online environment an important place for individuals to receive support. For instance, it is possible that direct/indirect support received online increases the sustainability of progress achieved via offline support and treatment. Perhaps the most beneficial aspect of online support forums, however, is that such venues create a space where shared experiences create an environment that is at the same time supportive and informative (Coulson, 2005). Additionally, and very importantly, the information stocked on such a forum can be accessed and used at any time. Such a feature is unique to the online sphere and it cannot be replicated in a traditional, face-to-face, setting, where interaction between the patient and the professional health provider is fairly regulated, unidirectional, and time-constrained (Coulson, 2005).

At the same time, we need to exert caution with respect to the benefits of online support for men with eating disorders. While this study, as well as previous research, has found solid evidence in favor of such benefits, it was also suggested that progress in dealing with eating disorders might be hampered by participation in such forums (Keski-Rahkonen & Tozzi, 2005). Although the forum investigated here is strictly moderated, the possibility that inadvertent advice is provided and/or taken cannot be excluded. However, based on our findings and previous research, we suggest that practices dealing with men with eating disorders could develop an approach that circumvents the shortcomings of both online and offline while incorporating their respective strengths. Specifically, traditional practices, in addition to their face-to-face services, could develop online platforms of support for their patients, exerting strict and professional moderation of these forums. Further, by promoting the existence of their own online forums, clinicians may find more men who axe willing to discuss their disorder--possibly serving to increase reporting of eating disorders in men.

Perhaps not surprisingly, the demarcation line between the online and offline worlds becomes blurry in the context discussed here. In what might be an important finding for the reconceptualization of social support in an online context, we saw multiple examples in which participants seemed to have forged bonds that had the intensity of face-to-face friendships, only to realize that the interaction was taking place in an online environment:

(Poster 1)

I don't have anyone to call a friend aside from my girlfriend [...] The isolation seems to offer a lot more familiarity and I guess comfort than real people, it's just too taxing for me. You don't happen to live in Ohio do you? We could probably hang out if you did by some crazy chance ... keep your head up the best you can buddy.

(Poster 2)

Funny man ... wish we did live closer. Thanks though: I am in FL. You keep your chin up, too.

Addressing theme three, we found social support occurring both in the forms of providing and seeking help, though the former was much more prominent. As discussed above, participants in online support groups might benefit in ways that are less accessible in the offline world. It is likely that, in face-to-face interactions, individuals are more likely to offer rather than seek support, for reasons of maintaining a strong "face." However, in an online context, some of this pressure might be circumvented. Future research will benefit from measuring the impact of providing versus seeking help as forms of support in online forums. Currently, it is not known whether forum members prefer providing support, or conversely, are less willing to seek it explicitly.

The fourth theme, the impact of masculinity norms on men in an eating disorder forum, may raise more questions than answers. As past research has demonstrated, men are typically less likely to disclose personal information or share their emotions than women and more likely to provide fact-based information (Mo et al., 2009). Interestingly, the present findings seem to run counter to traditional gender norms. Thus, as some more recent research has suggested, perhaps the use of masculinity norms is not an effective tool for the analyses of online communication (Fletcher & St. George, 2010).

However, the specific health issue addressed may have something to do with the conflicting results. Past studies that have found men to adhere to gender norms when communicating online focused on less "male taboo" health issues than eating disorders such as irritable bowel syndrome (Coulson, 2005), and prostate cancer (Blank et al., 2010; Mo et al., 2009). It is possible that the social stigma against men with eating disorders is so strong that the relatively anonymous space provided in online forums is the only venue many men feel comfortable to disclose the details of their personal eating struggles. In that case, the stark contrast between how men interact in face-to-face help seeking contexts and online forums may actually demonstrate strong adherence to masculinity norms in both contexts. A common gender norm may exists for men to "take advantage" of the online environment because of the social stigma against them discussing their eating disorders offline. Interestingly, in their examination of a predominately female eating disorder forum, McCormick and Coulson (2009) found information exchange to be more common than personal disclosure. It may be that women with eating disorders do not feel the need to disclose as much as men when online because they do not have the same degree of social opposition to doing so offline. Of course, without additional analysis, perhaps in the form of in-depth interviews, such a conclusion is speculative at best.

Lastly, another important finding of this study highlights the importance of maintaining a positive atmosphere on the forum as a key component of creating successful social support. The importance of minimizing negative posts and focusing on positive or at least optimistic posts was stressed not only in the forum rules and regulations, but it was also maintained and affirmed by members repeatedly. Although this issue requires further, more focused research, our data support previous findings (Peterson, 2009) with regard to the importance of creating and maintaining a positive atmosphere in support groups. Specifically, data indicate that, by maintaining an optimistic, positive tone, a sense of hope and camaraderie is created among members; this, in turn, might enable posters to maintain membership with the forum and thus facilitates the exchange of information and creation of bonds that help reduce one's uncertainty and stress. Peterson (2009), however, also questioned the "positive only" tone of online support groups, noting that such a feature may negatively impact some group members. This issue may be even more critical to examine in the context of eating disorder support groups where administrators rationalize the strict "positive only" rules as crucial so that members can avoid potential triggers for their eating disorders. Future research endeavors should address the effects of "positive only" rules for members' comments on eating disorder support groups.

CONCLUSION

This investigation sought to understand the dynamics of support received by men on eating disorder forums. Consistent with the social support framework, many forms of support were present including informational, emotional, personal disclosure, advice, and gratitude. This study also expands past research on eating disorder forums by including perspectives from a male group. Although similar categories and themes emerged here as in past research, the extent to which each was present differed considerably. Also, new categories and themes emerged. Still, further research is necessary to gain greater insight into social support in male eating disorder forums. If men who are less likely to disclose their eating disorders can gain the confidence to do so online, thrums like the one discussed here may prove extremely useful in the support and treatment process. Men from around the world were able to meet in this relatively anonymous online space to discuss their eating disorders and do so reasonably void of the cultural stigma that prevents many men from receiving offline support. Indeed, posters repeatedly stressed the importance of their group membership and that the support and encouragement they received from other members was a crucial aspect of their efforts on the road to recovery.

Our study concentrated on only one forum, this being its most obvious limitation. Future research will have to extend this type of thematic analysis to similar discussion groups. Also, as previous literature shows, there are significant differences between age groups with eating disorders. Specifically investigating the potential differences in how different age groups establish online social support may yield important new insights. In particular, adolescent males are a segment of the population that has seen a rapid increase in eating disorders diagnosis in recent years. Additionally, given the current findings and the inconsistencies in past research, examining masculinity norms and help seeking online is an area that would benefit from further inquiry. Lastly, and perhaps related to the theme of masculinity, future research should engage in investigations seeking to better understand the relationship between online and offline support. In particular, how important is online support for the recovery of men with eating disorders? How can these online forums be improved to facilitate greater support for more men? How can clinicians use online support in their efforts to help men not only make initial disclosures but also help in recovery? Seeking answers to such questions will be useful to address this growing societal issue.

DOI: 10,3149/jmh,1102.150

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MARK A. FLYNN, PH.D. * AND ALEXANDRU STANA, ABD *

* Bowling Green State University.

Correspondence concerning this article should be addressed to Mark A. Flynn. 219 West Hall, School of Media & Communication, Bowling Green State University, Bowling Green, OH. Email: flynnm@bgsu.edu
Table 1

Social Support Categories

Category                       Examples

1.     Request/Provide         We also have the added dimension that
       Personal Disclosure     it isn't socially acceptable for men,
                               which, at least for me, makes me feel
                               isolated and alone.

2.     Request/Provide         You are not alone!
       Emotional Support

3.     Provide /               Males represent about ******** percent
       Seek Information        of people suffering from anorexia
                               disorder; You ever get your hormones
                               tested?

4.     Request/                I would recommend seeing a
       Provide Advice          nutritionist if possible, and
                               attending a program for compulsive
                               eating.

5.     Request/Provide         I will keep posting here as there are
       Emotional Expression    times where I feel I just need to let
                               "someone" know that everything is not
                               alright.

6.     Display Gratitude       Thanks guys for all your help and
                               advice, I must admit I wasn't keen to
                               get off my butt and tell the world
                               that there is something wrong.

7.     Board Maintenance       It is against the rules of the site to
                               share how much you weigh, what size
                               you are, your BMI, caloric intake,
                               etc.

Table 2

Number and Percentage of Idea Units in Each Message Category

Category                           Number      Percentage
                                  of Units

Provide Personal Disclosure          464        33.8
Request Personal Disclosure           52         3.8
Provide Emotional Support            318        23.2
Request Emotional Support             45         3.2
Provide Information                  129         9.4
Seek Information                      24         1.7
Provide Advice                       127         9.3
Request Advice                         5         0.4
Provide Emotional Expression         125         9.1
Request Emotional Expression           4         0.3
Display Gratitude                     68         5.0
Board Maintenance                     11         0.8

Total                               1,372      100
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