Anorexia was first described in males by both Morton (57) and Gull (58). Anorexia in males accounted for approximately six percent of cases seen in an eating disorder clinic (38,59). Anorexia may be underdiagnosed because many physicians, as well as the anorectics themselves, are unaware that this condition occurs in both sexes.

The mean age of onset of male anorexia has been reported ranging from as young as 17 years in a British series by Crisp and Burns (47) to 24 years (38,60). Crisp found that the illness was present an average of three and one-half years and that most patients were mildly obese (127.3 percent of ideal body weight, IBW) prior to the onset of illness. Minimal weight dropped to 67.3 percent of IBW (60) during the acute phase of illness.

Apparently contrasting socioeconomic groups of origin for male anorectics may represent specific populations, seen in various programs. Andersen and Mickalide (48) found a high socioeconomic group at Johns Hopkins, while Herzog (38) in Boston and Verdereycken and Van den Broucke (59) in Belgium found an even socioeconomic distribution.

Clinical manifestations of male anorexia were reported in several series to be similar to female anorexia (43,47,49,59,61,62,63). However, in a minority of reports (51,64) differences were noted; patients were from lower socioeconomic groups, feared competition, and were not successful either academically or in their vocation.

Clinical manifestations of two male anorectics reveal differences in presentation from female counterparts. Male patients are usually more active, have more sexual anxiety, have fewer bulimic episodes, with less vomiting or laxative abuse, and, on a personality inventory, indicated more preoccupation with food and weight, more achievement orientation, and more physical complaints (65).

Endocrine changes (diminished testosterone level) in male anorectics may have a role in diminishing conscious sexual concern or conflict, which may be congruent with inhibitory physiological defenses.

Yates et al. (66) compared male marathon runners to anorectics and found many similar sociocultural and personality characteristics. Runners were found to have a bizzare preoccupation with food, and even when they would achieve a lean body mass of 95 percent with only five percent body fat, they would aim for four percent body fat. Many have lost greater than 25 percent of their original weight and show a relentless pursuit of thinness or a disturbance of body image. Yates suggests male runners are searching for identity. She raises the question, "Do anorexia nervosa in females and obligatory running in males share a common psychopathology?"

Male anorectic characteristics include perfectionism and obsession (48). Vandereycken and Van den Broucke (59) noted a high incidence of schizoid/introversion features (30 percent) as well as obsessional (29 percent), passive/dependent (15 percent) and anti-social features (18 percent). A comparison to female anorectics showed a higher percentage of undifferentiated-immature psychological structure (30 percent versus four percent), hysterical/histrionic features (25 percent versus four percent), and anti-social features (18 percent versus one percent), but an equal number of schizoid/introversion traits (28 percent).

The etiology of male anorexia is unclear, but Crisp and Burns (47) hypothesize that it is related to major gender identity problems in the premorbid personality, since the male desire is to be bigger and stronger as compared to the female preference for slimness. Herzog (38) found male anorexic patients experiencing sexual isolation, sexual inactivity, and conflicted homosexuality. He posited that the cultural pressure on the homosexual male to be thin and attractive places him at a greater risk for eating disorders. Undefined intrapsychic factors may promote an association between conflicted homosexuality and eating disorders.

Hall (43) in a series of nine male patients whose personal family history was reviewed, noted attention directed to bodily concerns caused by being overweight (2/9), having close contact with an eating-disordered patient (2/9), attempting to identify with a thin family member (2/9), attempting to treat acne through a stringent diet (2/9), and attempting to deal with the fear of having cancer (1/9).

Precipitating events of male anorexia nervosa include overwhelming stress such as divorce, children leaving for college, increased job responsibility, and a family member who becomes serious ill (48).

Endocrine disturbances present in pre-treatment male anorexia include decreased testosterone and gonadotrophins (luteinizing hormone-LH and follicle stimulating hormone-FSH) in proportion to weight loss. With weight gain, both testosterone and gonadotrophins increase to normal levels (48,53,54). Andersen and Mickalide (48) noted that two of ten patients were infertile. The creased testosterone may also result in depression of the bone marrow.

Anorexia in males has associated medical disorders such as anemia and abnormal liver function (48). There are also associated metabolic abnormalities such as self-induced vomiting, resulting in hypokalemic alkalosis (59).

Treatment of Male Anorexia Nervosa

Inpatient treatment of anorexic patients may be necessary if emaciation and medical complications are severe (60), but many patients can be managed on an outpatient basis. Ziesat and Ferguson (67) used a multimodal approach to contingency management, cognitive therapy, and dynamic psychotherapy. Andersen (45) comprehensively summarized treatment.

Prognosis was considered worse for male anorectics (50,51). Poor outcome was associated with a strained relationship between a patient and his parents during childhood, absence of adolescent sexual behavior and fantasy, long duration of the illness, and greater weight loss during illness (68). Andersen (45) however, suggests a more optimistic outcome even though psychopathology may persist despite diminished disturbance.

Summary

Male anorexia may be differentiated from female anorexia, since males are usually overweight (123.7 percent of ideal body weight, IBW) prior to developing the full anorexia nervosa disorder. In contrast, females are usually within 90 percent of ideal body weight prior to illness and may have a milder atypical form (48). Overall, however, male anorexia nervosa has more commonalities than differences with female anorexia (59,62).