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Adolescent boys and anorexia nervosa.

Anorexia Nervosa is an eating disorder that primarily affects adolescent girls and young adult females, and is considered to be rare among males. It is estimated that 1 in 200 adolescents between the ages of 12 and 18, the high risk group, develop anorexia nervosa and 90% of those affected are females (NIMH, 1987). There has been a steady increase in the reported incidence of male anorectics, from approximately 5% in 1985 (DSM III) to as much as 10% in 1987 (NIMH, 1987). Due to the cultural pressures for girls to be thin, professionals and parents are alert to the potential for risky dietary behavior; however, many male anorectics remain unnoticed.

A national survey (Gallup, 1985) found that 1 teenage girl in 8, and 4% of teenage boys had serious symptoms of anorexia nervosa and bulimia, and that one-third of both adolescent boys and girls have engaged in food binges. It also found that more than half of these adolescents resort to vigorous exercise, fasting, vomiting, and using purgatives to control their weight. Thus, contrary to common perception, these statistics indicate that boys as well as girls are engaging in destructive dietary practices.

The effects of anorexia nervosa can be devastating to the family and friends of the anorectic. More importantly, approximately 5% of the victims die prematurely due to starvation and its complications (DSM III). Anorexia nervosa in males may even be more prevalent than the reported estimates indicate. Like the female the male denies that he is ill. If he does seek professional help, it most likely will be for an endocrine or gastrointestinal problem, which is a consequence of anorexia nervosa. The physical problem may conceal the eating disorder from the clinician who generally suspects anorexia nervosa only in females. Thus, there may be more male anorectics receiving medical attention, but who are not diagnosed as anorectic. Thus, whenever an adolescent boy or young adult male presents with significant weight loss, the possibility of a diagnosis of anorexia should be considered.

Anorexia nervosa results from cultural, physical, and psychological pressures on vulnerable adolescents or young adults. The victims have a distorted and irrational attitude toward eating, food, and body weight. Some clinicians believe that anorexia nervosa may vary in severity, which makes it difficult to identify among the large number of adolescent dieters.

The essential features of anorexia nervosa include: intense fear of becoming obese; disturbance of body image; significant weight loss; refusal to maintain body weight beyond the minimal normal weight based on age and height; and no known physical illness that could account for the weight loss (DSM III). In general, primary anorexia nervosa is similar for both males and females, except for one symptom females experience amenohea, a cessation of menstruation.

Course of the Disorder

The teenage boy or young adult male will announce that he is going on a diet to lose a few pounds. He begins by reducing his intake of carbohydrates and fat-containing foods. In addition, he will exercise to further reduce his weight. Even after he reaches his weight-loss goal, he continues dieting and weighs himself frequently. He often declares that he is "fat." Parents and friends become concerned about his weight loss and encourage him to eat more, but he refuses. He will adamantly declare that he is still "too fat." The anorectic suffers from a body image disturbance; he cannot recognize that he is too thin or when the disorder progresses, that he is emaciated.

Some anorectics lose control over their severely restrictive diet and binge. A binge can be defined differently by anorectics. For some, a binge may consist of straying from their diet by as little as one calorie; for others a binge may involve hundreds of calories. Intense anxiety may be experienced after a binge which the anorectic may reduce by immediately eliminating the food, either by self-induced vomiting, laxatives, or vigorous exercising. Male anorectics generally prefer to increase the amount of exercise rather than use the other methods. Afterwards, the dieting becomes more obsessive, and hyperactivity may increase. Anorectics often report that they were overweight prior to the onset of the disorder, although not always excessively. They also report that other members of the family, a parent or sibling, are also on a diet. Some have stated that they started to diet because they were teased by others and did not want to be called "fatso" or "blimp."

Cultural Pressures

The cultural pressure from the advertising industry is for females to be thin. As a result, they represent the greater proportion of anorexia nervosa victims. The male anorectic's emphasis on exercising is also consistent with cultural pressures. The association of athletics and anorexia nervosa in males is particularly relevant in the sport of running because they prefer to exercise alone. Runners share some of the characteristics with anorectics. They desire to maintain a lean body mass, and endure considerable physical discomfort in the running process. However, the male anorectic's exercising and dieting are out of control. As a result, he suffers from poor health and is unable to attain the physical fitness required for competition in athletic events.

Psychological Pressures

Primary anorexia nervosa in males may start between the ages of prepuberty and young adulthood. However, it typically begins in prepuberty. Several psychological issues are related to the adolescent development stage. They include such problems as abnormally low self-esteem, sexual identify formation, and independent self-directed behavior. Anorexia nervosa serves as protection against conflicts associated with maturation.

Low Self-Esteem

One characteristic of anorectics prior to and during the disorder is that they are achievement oriented. Before becoming sick, they were successful in school work, and for many, in athletics. They received praise and encouragement from parents, teachers, and friends for their accomplishments. The family environment is generally high in expectations of perfection. In striving to achieve these high standards, they often suffer from low self-esteem and feelings of inadequacy. But their drive for achievement persists in spite of severe emaciation.

For adolescent boys, participation in a way is to achieve status and recognition. Some state that their fathers pressured them to excel in sports or to have a muscular physique. A change in their environment can also be threatening since they may no longer be assured of whatever status they may have achieved. This may trigger the onset of the illness in those who are vulnerable.

Sexual Identity Formation

A developmental task for adolescents is the establishment of an appropriate sexual identity, which in turn, leads to intimate heterosexual relationships and separation from their parents. As they experience the development of their secondary sexual characteristics, they face the need to establish their male role in society. In our culture, masculinity is defined by a strong and muscular physique. However, the anorectic's dieting behavior alters his physical appearance in direct contrast to the cultural ideal. Through the illness, many anorectics are retreating from the pressure to establish a male sexual identity. By altering his body through severe dieting and exercise, the anorectic retains a pre-pubertal physical appearance. Clinicians suggest that anorexia nervosa is associated with severe gender identity problems, and some report significant homosexual conflict prior to the onset of the disorder.


For some anorectic boys, the psychological dynamics suggest disturbed parental relations. They report that their father is emotionally distant and/or domineering, while the mother is described as overly protective. Some mothers of anorectics are considered to be controlling and overly protective. One consequence of this behavior is the inhibition of the child's development of autonomy and independence. Thus, the boy lacks the experiences necessary to provide the confidence needed for self-initiated behavior, and is ill-equipped to cope with the maturational demands of adolescence. The outcome is a robot-like compliance by the child who seems to succeed and to function well until life situations demand more independent decision making.

Thus, the anorectic boy is desperately in need of a feeling of mastery over his life. Some anorectics feel that they have lived under the control of other people, and that dieting is a way of gaining control. The strict monitoring of food intake and body weight is tangible evidence that at least his own body is under his control. Unfortunately, the process is self-defeating. Eventually, many become so weak, they require emergency medical treatment.


The anorectic requires a comprehensive treatment strategy that usually involves the services of a team of professionals: physician, psychologist or psychiatrist, dietician, and social worker. Hospitalization is required if the severity of the malnutrition is life-threatening. In the hospital, the anorectic may receive a combination of therapies: nutritional, individual, group, and family. Even after the anorectic improves, therapy usually continues upon release.


Only about one-third of female victims of anorexia nervosa completely recover. Clinicians report that the prognosis is even poorer for male anorectics. It appears that males are generally more resistant to treatment. Some professionals believe that the psychological dynamics of gender-identity issues may be associated with the poorer outcomes. These outcomes are also associated with long duration of illness and greater weight.


Given the severity of the disorder, particularly among boys, there is a need to identify anorexic boys in the early stages of the disorder in order to prevent the devastating medical complications resulting from starvation. Since the male anorectic may seek medical attention for gastrointestinal discomfort, physicians need to consider the possibility of this diagnosis in teenage boys with significant weight loss.

Educators have focused their programs on obesity and restrictive dieting techniques. The curriculum needs to include information on how to manage weight, aerobic exercise, and proper nutrition. The detrimental effects of anorexia nervosa should be included in the curriculum, since students are the first to recognize the disorder in their classmates. This is seen in the anorectic's distorted attitude toward eating during lunch hour. Weight loss is also noticed when the anorectic changes his clothes for physical education class. If peers inform a teacher or counselor about their concerns, early intervention can be instituted.

Since anorectics lack the self-confidence necessary for independent functioning, parents need to provide support and experiences in self-directed behavior and decision making. In addition, parents need to communicate their love and acceptance regardless of their children's physical appearance. Our society places too much emphasis on thinness.


DSM III. (1985). American Psychiatric Association, Washington, DC.

Eating Disorders. The Impact on Children-Families, Hearing Before The Select Committees on Children, Youth and Families, House of Representatives, Washington, DC, 1987.

National Gallup Poll, November 1985.

National Institute of Mental Health Survey (NIMH) (1987), Washington, DC.
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Author:Romeo, Felicia
Date:Sep 22, 1994
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