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Section 25
Anorexia in Males

Question 25 | Test | Table of Contents

It is estimated that males generally account for 5% to 10% of reported cases of anorexia nervosa (Alexander-Mott, 1994; Anorexia Nervosa and Related Eating Disorders, Inc., 1998). These figures must be viewed with caution however, because this disorder is likely underreported and misdiagnosed in the male population.

Current literature is saturated with numerous explanations, causes, treatments, and prevention of anorexia nervosa. Despite voluminous articles, papers, and books written on this topic, little mention is ever made to males. Keel, Fulkerson, and Leon (1997) reported their search of the literature revealed no studies of eating disorders in early adolescent males, and most research on predictors of eating disorders has been based on female samples. As a result, these findings may not generalize to males. In fact, there may be other factors present in predicting poor body image, low self-esteem, and resulting eating disorders in males. It is essential to determine the existence of any gender differences that might be affecting body image as a means of providing more appropriate prevention and intervention in this population. Kinzl, Mangweth, Traweger, and Biebl (1997) lamented the lack of studies performed with males. Keel et al. (1997) suggested how boys feel about their bodies can influence their tendencies toward anorexia. The factors that may determine this are still unknown, because the variables used in their study were determined by previous research based on females. Carlat, Carmago, and Herzog (1997) contended that in the past 300 years since anorexia nervosa was first described, there continues to be very little written regarding males and eating disorders and that the majority of the research has been limited to case reports or case-control studies.

Unique Aspects In The Development Of Male Anorexic Behavior
Halperin (1996) suggested that unlike girls, boys form an image of their bodies from participation in sports as the socialization of a team activity reinforces an outside source of acceptance. Kearney-Cooke and Steichen-Asch (1990) in their study of male body image and eating disorders found that from birth, boys become indoctrinated with what it means to be a man. They hold the belief that this entails a certain set of attitudes and behaviors that exude independence, a preoccupation with career, competitiveness, physical strength, aggressiveness, and courage. When the young male has difficulty obtaining these goals, emotional isolation occurs, which results in problematic behavior. Research has demonstrated that males with eating disorders exhibit a psychological profile that is analogous to females with eating disorders, encompassing both a sense of interpersonal ineffectiveness and an inability to control their emotions (DeAngelis, 1997).

Anderson (1992) reported that while the disorders may appear the same for both males and females, the course for getting there is quite different. "When individuals are very ill, suffering from emaciation or abnormal electrolytes and other medical complications, they appear very similar and require similar treatment ... but as patients become medically healthy and the symptoms are deconstructed, the individual life story behind each patient unfolds to reveal differences between the sexes in predisposition, course, and onset". Anderson (1992) suggested that males who develop eating disorders differ from females in three major areas of dieting behaviors. The first involves the reasons for dieting. He contended females diet because they feel fat, whereas males diet because they have been overweight at some point in their lives. Secondly, males more often than females diet to attain certain goals in sports or to avoid some type of sports-related injury that would be related to a weight gain. Thirdly, there is a greater preponderance of men who diet to avoid potential medical problems. Males may think that dieting and exercise will allow them to feel more masculine and more in control which, in turn, will lead to greater respect from others. A higher incidence of homosexuality or gender-identity confusion has also been reported among males with disordered eating patterns with estimates as high as 21% of affected males being homosexual (Anderson, 1999; Anderson, 1990; Siever, 1994). Kearney-Cooke and Steichen-Asch (1990) reported that males with eating disorders tend to have close relationships with their mothers and are more likely to have experienced ridicule from their peers in response to their physical appearance.

Social And Cultural Influences
For years the media have beckoned us to achieve a certain physical ideal. As the male physique increasingly becomes in demand for selling every product from soda to underwear, so too does the pressure to conform to a specific body type. Dorian and Garfinkel (1999) reported: "Anorexia nervosa and bulimia nervosa have been considered to be influenced by cultural forces; as these forces change, the disorders themselves may be altered. ... Awareness of the impact of sociocultural forces is critical to enhancing the understanding of the etiology and pathogenesis and to informing models of care."  Goldfield, Harper, and Blouin (1998) suggested that an increase in body-building and weightlifting has paralleled sociocultural norms with a meso-morphic build as the new ideal male body type. They further attested that individuals with eating disorders are likely to gravitate towards this type of sport to compensate for their body image disturbances and achieve personal and societal standards of attractiveness.
 
Gender Bias In Diagnosing Anorexia Nervosa
One reason for the misdiagnosis of male anorexia is due to the criteria used in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association). Anderson (1990) stated, "The diagnosis of males with eating disorders is usually a straightforward process, but as with appendicitis, you have to first think of it as a possibility" (p. 133). One of the hallmark features used to diagnose anorexia is amenorrhea, but currently there is no analogous criterion for males. Instead the endocrine disturbance males encounter is a general decline in the levels of testosterone production, which results in diminished sexual desire and performance (Carlat et al., 1997; Herzog, Bradburn, & Newman, 1990). Research has examined hypogonadism and has discovered that a reduction in gonadotropin secretion in anorexic males may be a corresponding feature to amenorrhea (Herzog et al., 1990; Burge, Lanzi, Skarda, & Eaton, 1997).

Implications For Mental Health Professionals
Presenting features for male and female anorexia are similar because they share many of the same attributes of the disease. As such, an awareness of the underlying psychopathology, course, and onset must be addressed (Anderson, 1990), but mental health professionals need to first consider this a possible diagnosis. When anorexia is suspected in males, treatment should proceed much as it does with the female anorexic, working from a multidisciplinary approach with an emphasis on medical intervention, education, weight restoration, and psychotherapy.

To assist mental health counselors who have infrequent contact with eating disordered males, a checklist with common features of male anorexia may be useful for diagnosis and treatment.  Male anorexics like their female counterparts possess high body dissatisfaction (Goldfield et al., 1998; Pope, Katz, & Hudson, 1993; Pope, Olivardia, Gruber, & Borowiecki, 1999).  In contrast to female anorexics, the majority of males have been overweight prior to the development of anorexia nervosa (Anderson, 1990).  In addition to dieting, excessive exercise is often a precursor to anorexic behavior (Paxton et al., 1991; Davis, 1999). Sexual orientation and sex role identification may be a concern (Anderson, 1999; Braun, 1997; Herzog, et al. 1990; Siever, 1994). Social withdrawal or the tendency to be a "loner" is common (Levine, Petrie, Gotthardt, & Sevig, 1990). Characterological traits are often present with borderline, obsessive-com-pulsive, dependent, passive-aggressive, and avoidant features being the most prominent (Braun, 1997; Kearney-Cooke & Steichen-Asch, 1990). Dysphoric mood is common (Anderson, 1990; Mickley, 1994). The production of testosterone gradually decreases in anorexic males as a result of starvation (Anderson, 1999; Burge et al., 1997; Herzog et al., 1990).  A loss of sex drive is experienced and sexual function diminishes (Anderson, 1990; Herzog et al., 1990).  Like females, male anorexics are often perfectionists with low self-esteem, living life to the extreme while engaging in all-or-nothing thinking (Pelch, 1992).
- Crosscope-Happel, Cindy; Hutchins, David E.; Getz, Hildy G.; Hayes, Gerald L.; Male Anorexia Nervosa: A New Focus; Journal of Mental Health Counseling, Oct2000, Vol. 22 Issue 4, p365

Personal Reflection Exercise #11
The preceding section contained information about anorexia in males.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
"The male elephant in the room":
a qualitative evidence synthesis exploring
male experiences of eating disorders

Coopey, E., & Johnson, G. (2022). "The male elephant in the room": a qualitative evidence synthesis exploring male experiences of eating disorders. Journal of eating disorders, 10(1), 131. https://doi.org/10.1186/s40337-022-00614-w

Peer-Reviewed Journal Article References:
 Criscuolo, M., Marchetto, C., Chianello, I., Cereser, L., Castiglioni, M. C., Salvo, P., Vicari, S., & Zanna, V. (2020). Family functioning, coparenting, and parents’ ability to manage conflict in adolescent anorexia nervosa subtypes. Families, Systems, & Health, 38(2), 151–161.

Raykos, B. C., Erceg-Hurn, D. M., McEvoy, P. M., Fursland, A., & Waller, G. (2018). Severe and enduring anorexia nervosa? Illness severity and duration are unrelated to outcomes from cognitive behaviour therapy. Journal of Consulting and Clinical Psychology, 86(8), 702–709.

Wong, T. K. Y., Konishi, C., & Zhao, K. (2018). Anger and anger regulation among adolescents: A consideration of sex and age differences. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 50(1), 1–8.

QUESTION 25
According to Crosscope-Happel, what percentage of anorexia nervosa cases are men? To select and enter your answer go to Test.

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