Also see Bulima
in males and Atypical eating
disorders in males
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
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
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.
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