Male Anorexia Nervosa: A New Focus.

Anorexia nervosa is a serious disorder that affects over 1 million males yearly (National Association of Anorexia and Associated Disorders, 2000). Despite this statistic, anorexia is often misdiagnosed or overlooked completely by both mental health and medical practitioners because of the misperception that it is a disorder exclusively present in females. The purpose of this article is to alert mental health counselors to the problem of male anorexia and outline salient features that are unique to these clients. With greater recognition of this potentially deadly disorder in males, more accurate diagnoses and, consequently, treatment will be the outcome.

PREVALENCE OF MALE ANOREXIA NERVOSA

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" (p.1).

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. (p.187)

Goldfield, Harper, and Blouin (1998) suggested that an increase in bodybuilding and weightlifting has paralleled sociocultural norms with a mesomorphic 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 fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). 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-compulsive, 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).

SUMMARY

The purpose of this article has been to alert mental health counselors to the severity of anorexia nervosa in males. To achieve this task, aspects of the disease were discussed and similarities between male and female anorexics were presented. Inferences regarding the misdiagnosis of male anorexics were also outlined. These included: counselor awareness, gender bias in the DSM-IV, social and cultural discrimination, and limited research on males and eating disorders. In addition, specific characteristics of the male anorexic were summarized. Male anorexia nervosa is a problem of great magnitude that requires heightened recognition from mental health and medical practitioners. Although it may not be as prevalent as some other psychiatric disorders, it demands attention and it is essential that the helping professions become acquainted with it and extend awareness to the broad community.

REFERENCES

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Cindy Crosscope-Happel, Ph.D., is a staff counselor at The Thomas E. Cook Counseling Center of Virginia Tech; David E. Hutchins, Ph.D., is a professor of Counselor Education in the Department of Leadership and Policy Studies; and Hildy G. Getz, Ed.D., is an assistant professor of Counselor Education in the Department of Leadership and Policy Studies; all are with Virginia Tech, Blacksburg, VA. Gerald L. Hayes, Ed.D., is a supervisor of Clinical Operations at American Psych Systems, Bethesda, MD.

Correspondence regarding this article should be sent to Dr. Crosscope-Happel, 7343 Riverbluff Road, Radford, VA 2414. Email [e-mail]