Eating disorders in adolescent males.

Research indicates that the primary onset of eating disorders occurs in adolescence and that there is a growing prevalence of adolescent males with eating disorders. In this article we describe the eating disorders of anorexia nervosa and bulimia nervosa as they relate to adolescent males. Diagnostic criteria, at-risk groups, and implications for school counselors are each discussed. The importance of the school counselor's role in identification, referral, psychoeducation, and support services for this population is critical.

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In the past several decades, professional and public awareness of eating disorders has increased, although eating disorders have been reported for hundreds of years (Reijonen, Pratt, Patel, & Greydanus, 2003). Commonly perceived to be a female affliction, it is ironic that the first documented clinical case of anorexia was in a male; additionally, males comprise between 10% to 15% of the eating disordered population (Johnson & Connors, 1987; Keel, Klump, Leon, & Fulkerson, 1998; Russell & Keel, 2002; Walcott, Pratt, & Patel, 2003). Specific prevalence rates among males are difficult to determine and may be higher than reported due to the hidden nature of eating disorders and the perception that eating disorders are found solely in females (American Psychiatric Association, 2000; Keel et al.; Patel, Pratt, & Greydanus, 2003; Reijonen et al.; Scheider, 1991). The societal stigma surrounding eating disorders is one of secrecy and shame; as a result, eating disordered males often go to great lengths to hide their condition (Patel, Pratt et al.; Scheider).

The primary age of onset of eating disorders, for both males and females, falls between 12 and 26 years with a peak onset age of 14 to 18 years (American Psychiatric Association, 2000; Phelps & Bajorek, 1991). One study examined prevalence rates for school-age youth and posited that 9% to 11% of all school-age youth met diagnostic criterion for eating disorders (cited in Reijonen et al., 2003). Due to the debilitating side effects of eating disorders--that include morbidity and mortality rates up to 12 times that of the typical adolescent population--appropriate early identification and early diagnosis are imperative (Reijonen et al.). The likelihood of higher than reported prevalence rates of males with eating disorders, in conjunction with the peak age of onset occurring in adolescence, underscores the importance of the school counselor's knowledge base in identifying eating disorders in male students.

This article provides diagnostic descriptions of the risk factors and etiology of eating disorders in the adolescent male population. A discussion of subpopulations that present with heightened risk factors ensues. In addition, implications for school counselors are included that provide information to assist the school counselor with his or her role in providing appropriate referrals, psychoeducational information, and support services. School counselors with an awareness of prevalence rates and etiology of eating disorders in adolescent males can successfully provide front-line assistance to these males in both at-risk and diagnostic groups (Felker & Stivers, 1994; Fischer et al., 1995; Nelson & Hughes, 1999; Patel, Pratt et al., 2003).

DESCRIPTION

The Diagnostic and Statistical Manual of Mental Disorders (4th ed. text rev., American Psychiatric Association, 2000) describes the criterion for the diagnosis of anorexia as the refusal to maintain a normal bodyweight as defined by weight of less than 85% of typical bodyweight for a given height as well as experiencing intense fear related to gaining weight. Young men comprise approximately 10% to 15% of those suffering from the disorder; the peak age of onset for both genders falls between 14 and 18 years. The negative health effects of the disease include: metabolic changes, emaciation, constipation, thyroid difficulty, heart abnormalities, and death (Reijonen et al., 2003). The mortality rate for individuals with anorexia proves greater than any other mental disorder and has been shown to be as high as 15% (American Psychiatric Association, 2000; Phelps & Bajorek, 1991; Reijonen et al.; Scheider, 1991). This alarming statistic, in conjunction with the primary age of onset occurring during the middle and high school years, underscores the importance of the school counselor's role in appropriate identification and understanding of the risk factors of anorexia.

According to the DSM-IV-TR (2000), individuals suffering from bulimia eat a large amount of food in a limited time period, experience a lack of control over eating during that time, engage in inappropriate purging behavior, display maladaptive eating patterns at least two times per week for 3 months, and are hypersensitive to weight fluctuations. Purging methods include: vomiting, laxative use, excessive exercise, or subsequent restricted food intake. Unlike those suffering from anorexia, individuals with bulimia are often of normal body weight and are better able to hide their disease. The currently reported prevalence rates represent 1% to 3% of the population in industrialized countries; however, actual rates may be considerably higher as the accuracy of these statistics remains suspect due to underreporting (American Psychiatric Association, 2000; Keel et al., 1998; Patel, Pratt et al., 2003; Reijonen et al., 2003; Scheider, 1991). Like anorexia, the typical range of onset for both genders occurs in the adolescent years (American Psychiatric Association; Lyon & Chatoor, 1997; Reijonen et al.).

AT-RISK GROUPS

There are several sub-populations of adolescent males that present with heightened risk factors. Adolescent males more at risk for developing eating disorders include those involved in athletic activities, struggling with sexual identity conflict, diagnosed with co-morbid mental disorders, or with a family history of eating disorders and a chaotic home environment. Knowledge regarding the heightened risk factors for this population proves important, especially since early identification of eating disorders improves treatment outcomes (Reijonen et al., 2003).

Athletes

Eating disorders occur to a greater degree in athletes than in the general population (Murphy & Gutekunst, 1997; Patel, Greydanus, Pratt, & Phillips, 2003). Adolescent athletes in sports with weight classifications and those engaging in activities where lean body types are preferred are at the highest risk for developing eating disorders (Patel, Greydanus, et al.). Assessing the percentage of male athletes suffering from either anorexia or bulimia proves even more difficult than in the general population due to a myriad of factors that include: methodological limitations from the current literature, assessments that rely on self-report, and lack of uniform criteria across studies (Murphy & Gutekunst; Patel, Greydanus, et al.).

Nelson and Hughes (1999) examined the risk factors of developing an eating disorder and also asserted that male athletes display increased susceptibility. This proves especially true in sports where body size and proportion remain under intense scrutiny. Nelson and Hughes discussed the elevated incidents of anorexia and bulimia in their male sample population and also suggested the likelihood of higher prevalence rates than previously suspected. They reported that there is minimal research literature addressing eating disorders in males and discussed the need for future research endeavors in this area.

Patel, Greydanus, et al. (2003) investigated prevalence rates for adolescent athletes and concurred with previous studies that posited the underestimation of incidents in the male athletic population. Patel, Greydanus, et al. specifically emphasized young men in sports that focus on body weight and body image--wrestling, swimming, track, rowing, and gymnastics. The pressure that these athletes put on themselves leads them to engage in maladaptive eating behaviors that prove dangerous to their physical health such as: excessive exercise, caloric and fluid restriction, laxative and diuretic use, self-induced vomiting, and starvation (Patel, Greydanus, et al.).

Diving, bodybuilding, gymnastics, and running represent additional sports that hold increased risk for the development of eating disorders. In these sports, the impact of body image is emphasized, the athletes are judged to some degree by physical appearance, and to be competitive they often demand extremely low percentages of body fat (Murphy & Gutekunst, 1997; Oliosi, Dalle Grave, & Burlini, 1999; Patel, Greydanus, et al., 2003). The belief of some athletes is that competing in a lower weight division or reducing their body fat index will increase their chances of winning. Both coaches and athletes tend to adopt this belief system to succeed. Ironically, the deleterious side effects of anorexia or bulimia often hinder their performance due to the health risks of disordered eating patterns that physically weaken the athletes and lead to decreased performance (Murphy & Gutekunst). Clearly, the demands placed on athletes to achieve and maintain a certain body weight put them at heightened risk for the development of eating disorders.

Sexual Identity

The relationship between sexual identity and eating disorders remains unclear; however, several studies posit that male homosexuals are at increased risk for developing eating disorders (Buroughs & Thompson, 2001; Walcott et al., 2003). Sexual isolation, sexual inactivity, and disturbed sexual identification have also been linked to the clinical population of eating disordered males. Buroughs and Thompson examined the sexual orientation of anorexic and bulimic males and found that the prevalence of homosexuality in the sample population was significantly higher than that of the general male population. The authors suggested that one possible explanation for their findings was the subversion of sexual conflict resulting from the side effect of decreased libido. Additionally, homosexual males may be more at risk for the development of eating disorders due to a heightened emphasis on physical attractiveness (Walcott et al.).

Manley, Rickson, and Standeven (2000) reported that boys present with anorexia at a significantly higher percentage than adult males, although they point out that the reasons for the growing prevalence in boys remains unclear. They comment on this possibly resulting from burgeoning sexual conflict emerging in the adolescent period. The lack of knowledge regarding the sexual characteristics of boys and men with eating disorders underscores the need for further research (Scheider, 1991; Walcott et al., 2003). Knowledge of the existing research in this area can benefit school counselors by providing them with an awareness of the additional risk that homosexual youth may face for the development of an eating disorder. This knowledge assists the school counselor with identification and represents the first step in the treatment process.

Mental Disorders

Co-morbid mental disorders that may provide warning signs for adolescent males at risk for the development of an eating disorder include: Mood Disorders, Substance Abuse and Dependence, and Personality Disorders (American Psychiatric Association, 2000). Specifically, a plethora of research studies displayed a predisposition to eating disorders among those diagnosed with depression (e.g., Fischer et al., 1995; Lyon & Chatoor, 1997; Moreno & Thelen, 1995; Nassar & Hodges, 1992; Pratt, Phillips, Greydanus, Pratt, & Patel, 2003; Pryor & Weiderman, 1998).

Features of Obsessive Compulsive Disorder are frequently seen in individuals suffering from anorexia and bulimia. The obsessive-compulsive behaviors focus on food, body image, and weight. Also, impulse control issues remain prevalent in males with bulimia; this links with Substance Abuse and Cluster B Personality Disorders such as Borderline, Histrionic, and Narcissistic as individuals with these diagnoses also display poor impulse control (American Psychiatric Association, 2000).

As with Personality Disorders and Mood Disorders, low self-esteem is often reported in eating disordered clients. This has been demonstrated in both subjective and objective accounts (American Psychiatric Association, 2000; Nassar & Hodges, 1992). School counselors aware of the link between eating disorders and the diagnoses enumerated in this section will have relevant information to assist them with accurate identification of students at risk.

Family Issues

Male adolescents who have a history of eating disorders in their family are at greater risk for the development of anorexia and bulimia (American Psychiatric Association, 2000; Felker & Stivers, 1994; Manley et al., 2000; Pratt, Pratt et al., 2003). Additionally, family environments that are tumultuous have been linked to decreased treatment effectiveness for eating disorders (Felker & Stivers; Manley et al.). Any recent intrafamilial loss such as death or divorce has also been identified as a risk factor. Finally, adolescent males in households where appearance and body image are emphasized remain at heightened risk for developing an eating disorder (Manley et al.).

IMPLICATIONS FOR SCHOOL COUNSELORS

School counselors can play a critical role in assisting male students either at-risk or currently battling an eating disorder (Manley et al., 2000; Russell & Keel, 2002). The following is a list of guidelines that will benefit school counselors in their work with adolescent males:

1. School counselors need to know the risk factors specific to adolescent males. These can be remembered as the "six red flags" of

* Age 14 to 18 years

* Athletes in sports that focus on body image and weight classifications

* Homosexuality or confusion related to sexual identification

* Any occurrence of the previously enumerated mental disorders that appear co-morbid with eating disorders

* Recent turmoil in the home environment that could trigger the onset of an eating disorder such as death of a loved one, divorce, moving, and financial difficulties

* Presence of family members suffering from an eating disorder as well as a family environment that stresses physical appearance and body image

2. School counselors should be aware of resources available in the community. This represents identification of referral agencies and practitioners who have experience working with this population. The school counselor's role in initiating appropriate community referral would include providing the student and his family with general information on community psychotherapeutic resources as well as emphasizing the importance of a medical evaluation to assess the general physical health of the client. The research has shown that treatment for eating disorders can encompass months of individual and group therapeutic interventions; this underscores the need for the school counselor to be aware of available community resources (Manley et al., 2000; Phillips, Greydanus, Pratt, & Patel, 2003).

3. School counselors can educate parents, teachers, coaches, and community members on the following: awareness of the signs and symptoms of eating disorders, prevalence rates in males, and each of the risk factors previously discussed. School counselors possess a critical knowledge base that can be incorporated into parent education programs and parent/teacher association presentations (Manley et al., 2000).

4. School counselors may monitor their students' progress in referred treatment as well as provide at school support for those students in outpatient counseling. School counselors can also assist by offering group counseling opportunities for at-risk or diagnosed male students (Phillips et al., 2003).

SUMMARY

The importance of understanding the etiology of eating disorders in males cannot be denied, especially when considering their deleterious effects on both mental and physical health (American Psychiatric Association, 2000; Reijonen et al., 2003). The insidious nature of these illnesses--secrecy, shame, physical health problems, and heightened mortality rates--engenders a professional responsibility in school counselors (Fisher et al., 1995; Nelson & Hughes, 1999; Patel, Pratt et al., 2003). School counselors can provide important services to students, parents, teachers, coaches, and community members that include: identification, referral, psychoeducation, and at-school support services. Due to their direct contact with students in the peak modal age group, school counselors remain in the position to play an active role in the battle against eating disorders in the adolescent male population.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. text rev.). Washington, DC: Author.

Buroughs, M., & Thompson, J. K. (2001). Exercise status and sexual orientation as moderators of body image disturbance and eating disorders in males. International Journal of Eating Disorders, 31 (3), 307-311.

Felker, K., & Stivers, C. (1994). The relationship of gender and family environment to eating disorder risk in adolescents. Adolescence, 29, 821-835.

Fischer, M., Golden, N., Katzman, D., Kreipe, R., Rees, J., Schebendach, J., et al. (1995). Eating disorders in adolescence. Journal of Adolescent Health, 16, 420-437.

Johnson, C., & Connors, M. (1987). The etiology and treatment of bulimia nervosa: A biopsychosocial perspective. New York: Basic Books.

Keel, P., Klump, K., Leon, G., & Fulkerson, J. (1998). Disordered eating in adolescent males from a school-based sample. International Journal of Eating Disorders, 23, 125-132.

Lyon, M., & Chatoor, I. (1997). Testing the hypothesis of the multidimensional model of anorexia nervosa in adolescents. Adolescence, 32, 101-112.

Manley, R., Rickson, S., & Standeven, 8. (2000). Children and adolescents with eating disorders: Strategies for school counselors. Intervention in School and Clinic, 35, 228-232.

Moreno, A., & Thelen, M. (1995). Eating behavior in junior high school females. Adolescence, 30, 1714-1728.

Murphy, S., & Gutekunst, L. (1997). Disordered eating among athletes: The athletic trainer's role. Washington, DC: Human Kinetics.

Nassar, C., & Hodges, P. (1992). Self-concept, eating attitudes, and dietary patterns in young adolescent girls. School Counselor, 39, 338-344.

Nelson, W., & Hughes, M. (1999). Anorexic eating attitudes and behaviors of male and female college students. Adolescence, 34, 621-644.

Oliosi, M., Dalle Grave, R., & Burlini, S. (1999). Eating attitudes in noncompetitive male body builders, international Journal of Eating Disorders, 7, 227-233.

Patel, D. R., Greydanus, D. E., Pratt, H. D., & Phillips, E. L. (2003). Eating disorders in adolescent athletes. Journal of Adolescent Research, 18, 280-296.

Patel, D. R., Pratt, H. D., & Greydanus, D. E. (2003).Treatment of adolescents with anorexia nervosa. Journal of Adolescent Research, 18, 244-260.

Phelps, L., & Bajorek, E. (1991). Eating disorders of the adolescent: Current issues in etiology, assessment, and treatment. School Psychology Review, 20, 9-23.

Phillips, E. L., Greydanus, D. E., Pratt, H. D., & Patel, D. R. (2003). Treatment of bulimia nervosa: Psychological and psychopharmacologic considerations. Journal of Adolescent Research, 18, 261-279.

Pratt, H. D., Phillips, E. L., Greydanus, D. E., Pratt, H. D., & Patel, D. R. (2003). Eating disorders in the adolescent population: Future directions. Journal of Adolescent Research, 18, 297-313.

Pryor, T., & Weiderman, M. (1998). Personality features and expressed concerns of adolescents with eating disorders. Adolescence, 33, 292-302.

Reijonen, J. H., Pratt, H. D., Patel, D. R., & Greydanus, D. E (2003). Eating disorders in the adolescent population: An overview. Journal of Adolescent Research, 18, 209-222.

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

Scheider, J. A. (1991). Gender identity issues in male bulimia nervosa. In C. Johnson (Ed.), Psychodynamic treatment of anorexia nervosa and bulimia (pp. 194-222). New York: Guilford.

Walcott, D. D., Pratt, H. D., & Patel, D. R. (2003). Adolescents and eating disorders: Gender, racial, ethnic, sociocultural, and socioeconomic issues. Journal of Adolescent Research, 18, 223-243.

Shannon L. Ray, Ph.D., LMHC, is graduate associate faculty, University of Central Florida, Orlando.