Justin Shamoun began to hate his body a few weeks into seventh grade. He was a year younger than his suburban Detroit classmates, having skipped a grade. Many of his peers were entering puberty, their bodies solidifying into sleek young men. Justin still had the doughy build of a boy. After gym class one day, someone told Justin he could probably run faster if he weren’t so fat.

The remark crushed him. Ashamed, he started hiding his body under ever-baggier clothes and making excuses to skip P.E., the pool, anywhere required to expose bare skin. Finally, he decided to fix himself. He dove headlong into sports and cut back on food. Before long, he was tossing his lunch into the garbage and picking at his dinner. He ate just enough to blunt his hunger, until the time came when he ate barely at all. The thought that he had an eating disorder never occurred to him.

Long considered an affliction of women, eating disorders — the most deadly of all mental illnesses — are increasingly affecting men. The National Eating Disorders Association predicts that 10 million American men alive today will be affected, but that number is only an estimate based on the limited research available. The official criteria for diagnosing eating disorders were updated to be more inclusive of men only in 2013. And last year, Australian researchers writing in the Journal of Eating Disorders noted that “the prevalence of extreme weight control behaviors, such as extreme dietary restriction and purging” may be increasing at a faster rate in men than women.

A generation ago, photos of half-naked, perfectly sculpted male bodies were largely confined to Calvin Klein underwear ads. Guys now have plenty of images to make them feel inadequate, as they are ever more exposed to a pop culture that celebrates athletes and superheroes with astoundingly chiseled physiques.

“The people you see on billboards and magazines and TV — it gave me something to compare myself to,” Shamoun said. “Every movie I watched, every singer. I could never be as successful as or look as good as ‘insert celebrity name here.’ ”

But many young men like Shamoun — bearing the double stigma of having a mental illness, and one classically categorized as female — insist they’re fine, not recognizing they’re sick or in need of help. Making matters worse, the medical profession itself has been slow to respond to the problem, too.

“Why do we not think that this is a male disease? Because even the academics aren’t bothering to put the time and effort into it,” said Andrew Walen, who became a therapist in Columbia, Md., after a 20-year battle with eating disorders. He pointed out that it took decades for women with eating disorders to emerge from shame and secrecy. Since men are only starting to come forward, “it could be 20 years before we see anybody really starting to speak up and say this is a problem that is epidemic.”

Women, of course, have been inundated with body pressures for decades — Twiggy debuted in the 1960s — but only recently have advocates succeeded in persuading at least some modeling agencies and magazines to feature a fuller range of the female form, and ban cover phrases like “bikini body” and “drop two sizes.” The objectification of men is newer and less pervasive, and less subject to soul searching, at least so far.

Consider that in late March, American Eagle released an ad featuring “real men” wearing the brand’s underwear. On April 1, the company announced that the whole thing had just been an April Fool’s joke to emphasize its pledge to stop retouching underwear ads.

Here’s another example: A version of this article was scheduled, and later dropped, by a men’s magazine.

A vastly underestimated problem

Women have long belittled their natural shapes, forced to come of age in a society where thinness reigns. While still an issue, an analysis of 250 studies presented last August at the American Psychological Association meeting found that body dissatisfaction is falling among women, but not men, who are persistently feeling pressured to build muscle.

“We’ve set up a physical ideal that a lot of men can’t reach, and then told them they can reach it,” said Drew Anderson of the University of Albany. “And if they don’t, it’s somehow their fault.”

The most common statistic maintains that 10 percent of those who suffer from eating disorders are male, a number that has been used to push men to the margins, says Leigh Cohn, the editor of Eating Disorders: The Journal of Treatment and Prevention. But he’s traced that passed-around figure to its source: an unscientific sampling at one clinic during the 1980s. Only now are mental health professionals starting to realize the degree to which they have vastly underestimated the problem, he said.

More than a decade ago, Cohn asked an auditorium full of eating-disorder specialists how many of them had male patients. He saw a scattering of hands. When he conducted the same informal poll in 2013 at the International Conference of Eating Disorders, he said, nearly every one of the 900 attendees raised a palm: “It was quite clear that over the period of about 10 years, clinicians went from a handful of people seeing males to almost everyone seeing males.”

One study, published in January 2014 in JAMA Pediatrics, reported that almost one boy in five from a national sample said he was “extremely” concerned about his weight, and not necessarily because he had any reason to be. Among teenagers and college-age men, 8 percent were engaging in unhealthy behaviors, even using steroids, to pack on muscle and lose fat.

Yet for the most part, treatment remains inherently female-focused. One example: An adult inpatient program in Dallas — established 22 years ago at Texas Health Presbyterian Hospital — was until 2015 housed in a women’s building and could not take male patients at all.

This is not unusual. The Journal of Eating Disorders report noted that most programs are skewed toward women, and implored for change, saying, “it is vital that barriers to help-seeking, such as stigma, ignorance more generally, and female-centric services, are addressed.”

‘I wasn’t a stick-thin supermodel’

Despite the fact that they are marked by extremes in calorie consumption, eating disorders concern far more than food. They can arise from a need to take charge of circumstances that otherwise feel uncontrollable, and often develop as a means to try to heal from abuse, trauma or bullying. The fellow in the mirror is never attractive enough, or smart enough, or worthy enough to have a meal and work out at a normal level.

They can coexist with other conditions such as drug and alcohol addiction or depression. Eating disorders occur at any age, but tend to emerge in adolescence and young adulthood. The most common forms are anorexia, bulimia, and binge eating, and for men, they are often accompanied by obsessive amounts of exercise to build muscle or burn calories.

“I was a guy who was super-athletic,” said Shamoun, who is now 23 and working at a New York City analytics firm. “I played soccer every day. I was running track and cross country,” he said. “I wasn’t a stick-thin supermodel.”

Many men diagnosed with eating disorders were once obese, and can’t stop fleeing from their former selves. Brian Cuban, a Dallas lawyer who battled bulimia for 25 years, grew up as a chunky kid who was chided and fat shamed. The problem began as a freshman desperate to fit in at Penn State.

“I would restrict, I would lose weight, and the affirmations came: ‘You’re looking great, Brian!’ I’m like, ‘Wow, okay, I’m accepted. I’m finally accepted.’ So I would restrict more,” he said. “No matter how thin I got, I still saw this fat, bullied little boy in the mirror. It wasn’t making me feel any better about myself.”

While girls still enter adolescence with greater appearance pressures, boys are increasingly presented with their own versions of Barbie. Far from the days of GI Joe, Justin Shamoun’s generation grew up playing with impossibly ripped action figures — even Luke and Han have the biceps of body builders — and wearing Halloween costumes that come padded with fake muscle.

The University of Albany’s Anderson said that traditionally, popular culture conveyed status and power in men through their possessions and the company of beautiful women. “At some point, we shifted that discussion from men of ‘Nice car, nice suit’ and that kind of stuff to, ‘You’ve got to have 5 percent body fat and a 45-inch chest.’ ”

Waking up to work out

Most men can take a mental inventory of everything they would like to improve without getting obsessed. Also, eating less and exercising more is an undoubtedly healthy way to grow stronger or lose a few pounds. In some men, though, probably owing to genetics, psychological distress or other reasons that aren’t understood, that desire for perfection becomes a fixation that dominates all else.

It starts to interfere with normal life: The guy who skips a best friend’s wedding because he doesn’t want to eat the banquet. Or who turns down a promotion because it might interfere with daily two-hour gym sessions.

Sometimes a man with an eating disorder will get up in the middle of the night to work out. A study presented at the American Psychological Association’s annual meeting in 2015 reported that about one-third of regular male gym-goers studied admitted to taking worrisome levels of bodybuilding supplements, some continuing even though they had developed kidney problems and their doctors advised them to stop.

“If you find yourself wanting to cut down, and not able to, that’s a sign that it’s problematic,” Anderson said. “You either can’t stop or are deathly afraid of what will happen to your body if you do stop: ‘I’ll lose all my muscle mass. I’ll get flabby. I’ll get soft. I’ll get scrawny again.’ ”

When Walen, the Maryland therapist, was trying to compensate for the uncontrollable urge to binge eat, he took up running. He ran so much he ground up the cartilage in his hips. “So I said, ‘Well, fine. Instead of being the smallest person, I’m going to be the most ripped person,’” Walen said.

He lifted weights compulsively and tore both rotator cuffs, requiring surgery to reconstruct both his shoulders. “And I continued to lift despite the intense pain. That’s the craziness of this disorder.”

Losing a grasp on logic

Growing up in Tulsa, Nate Nahmias plumped up in middle school, the inevitable consequence of a sedentary video-gaming life and side effects of a doctor’s prescription. He finally decided to do something about it, and restricted calories. By age 16, he was anorexic.

“I’d have this goal I’d want to weigh X amount, but in order to make sure that I didn’t break that goal and go the wrong way, I needed to kind of overshoot it a little bit,” he said. “And then overshooting just went to more and more and more and more, so I just kept dropping and dropping and dropping.”

A starving brain loses a grasp on logic. One now famous study took place at the University of Minnesota in the 1940s among 36 men who were conscientious objectors during World War II. For six months, they ate fewer than 1,800 calories a day, a level that reflected conditions in parts of war-torn Europe. They walked 22 miles each week.

Even though the calorie restriction was voluntary, the men developed symptoms often seen with eating disorders, such as depression and flirtations with suicide. Some lost the ability to think rationally; two were hospitalized for psychiatric concerns. One man cut off three of his fingers.

As with the men in the starvation experiment, Nahmias lost the ability to reason. His mom took him to a nutritionist who warned them that his amount of body fat was dangerously low, and gave him a number. “She said that to me and I’m thinking in my head, ‘I want to be lower than that,’” he recalled.

Yet when Nahmias eventually tried to find help, “It was extremely, ridiculously hard,” he said, to find programs that would accept, much less had experience, treating men. Nahmias eventually traveled from Oklahoma to Wisconsin, where he spent two months in intensive treatment. Now 26, he’s a chemical engineer in Houston. “I still struggle every day to one degree or another,” he said, “but it’s manageable.”

When men do seek treatment, they have usually been in denial for so long “they are much, much sicker” than women, said Dr. Carrie McAdams, a psychiatrist at UT Southwestern Medical Center at Dallas and a physician at the Presbyterian treatment program. Some are transferred directly from the intensive care unit. They’ve often cycled through five or six doctors — one of McAdams’ patients had seen 12 — who because of their own misconceptions didn’t recognize their patients had an eating disorder.

One sad benefit of more men falling ill is that medical professionals are tuning in to the special considerations of men. The unit in Dallas, for instance, has treated about a half-dozen men since moving from the women’s hospital last year. The medical director, psychiatrist Jennifer Giampaolo, acknowledges that it can be hard for men, when even the flowers on the walls remind them that their disease is seen as feminine. She’s sympathetic, pointing out that femininity itself is often culturally equated with weakness, which might make treatment that much more complex.

Making peace with his flaws

Justin Shamoun suffered until his freshman year at Cornell University, when he was making himself throw up several times a day and his grades were plummeting from physical and mental exhaustion. Finally, his friends confronted him.

“I had for so long been able to keep up this façade that everything in my life was great, that to admit to them that it wasn’t was the last thing I ever wanted to do,” he said. At first he dismissed their concerns. “I was like, “I don’t have that.”

A doctor at the campus health clinic laid out the facts: The lining of Shamoun’s esophagus was deteriorating from the stomach acid. His teeth were rotting. He was in danger of a heart attack. Finally, the denial ended, and he entered treatment.

Today, he eats and exercises, but neither to extremes. He just completed his first New York City marathon. “I could never have done it when I was in high school, because I just did not have enough energy to run a full marathon,” he said. He has regained a strength he hasn’t known since childhood.

For seven years, he told himself that he needed to be perfect to be happy. By making peace with his flaws, he discovered the joy of being fully human.

Republished with permission from STAT. This article originally appeared on December 28, 2016