Clinical picture in comparison to women
The incidence of anorexia nervosa in males is generally agreed upon to be between 5% to 10% of all anorexia nervosa cases. (Crisp & Burns, 1983) Studies show that there tends to be a predominance of the upper social class in cases of eating disorders with almost two thirds of the group from social classes I and II (Sharp, Clark, Dunan, Blackwood, & Shapiro, 1994). High risk subgroups include jockeys, wrestlers, dancers, and entertainers required to lose weight to be successful (Andersen, 1986). Andersen (1986) also suggests that the incidence in male medical students is several times greater than that of the general male population.

The DSM-IV criteria for anorexia nervosa include an intense fear of gaining weight, a distorted self-perception of body image, refusal to maintain normal body weight (less than 85% of expected weight) and three consecutive months of amenorrhea (American Psychiatric Association, 1994). The criterion of amenorrhea has been subject to much criticism for the creation of a gender bias in diagnosis of the disorder.Several suggestions have been proposed to eliminate this gender bias. Russell (as cited in Crisp & Burns, 1983) solves the problem by altering the amenorrhea criterion to an endocrine disorder which manifests itself clinical in amenorrhea, or in the case of male subjects, a loss of sexual interest and lack of potency. On the other hand, some suggest that the criterion be eliminated completely due to the fact that the illness is no less severe in patients who meet all the diagnostic criteria with the exception of amenorrhea (Andersen & Holman, 1987).

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The clinical picture of anorexia nervosa in males has been extensively researched and detailed. (Crisp & Burns, 1983; Sharp et al., 1994). Crisp and Burns (1983) gave a preliminary description of the clinical features found in 36 male patients being studied at St. Georges Hospital in London. They noted clinical data at two stages, the first at onset and the second at presentation. Sharp et al. (1994) followed up with a longitudinal study of 25 male anorexia nervosa patients at the Royal Edinburgh Hospital. They compared the clinical details at presentation of the male subjects to a group of 25 anorectic females.

In Crisp and Burns study (1983), the mean age at onset of anorexia nervosa was found to be 17 years and 2 months while the mean age at presentation was 20 years and 7 months. Sharp et al. (1994) presented similar statistics with a mean age at onset of 18.6 years and a mean age at presentation of 20.2 years. The female comparison group resulted in a mean age at onset of 17.5 years and a mean age at presentation of 19.8 years. The difference between the male a female groups is not statistically significant and similarity in this aspect can be concluded. However, comparison of mean duration of illness, 3.6 years (Crisp & Burns, 1983) versus 1.6 years (Sharp et al., 1994), suggests that the increase in awareness has led to earlier recognition and consequent treatment of the disorder.

The mean weight, measured as a percentage of the Matched Population Mean Weight (MPMW), was 101.3% MPMW at onset and 73.4% MPMW at presentation (Crisp & Burns, 1983). However, Sharp et al. (1994) showed a 114.7% MPMW at onset for males and 107.6% MPMW for females which agrees with Andersens (1986) suggestion that prior to dieting males are more likely to be clinically overweight. In addition, they reported 78.5% MPMW at presentation for their male group and 72.4% MPMW for their female group. The difference at presentation is statistically insignificant and it is more meaningful to examine the difference in mean weight loss between the studies. Crisp and Burns (1983) calculated a mean weight loss of 32.5% MPMW, a lower percentage than found in female clients, and attributed to men having lower levels of fat to lose. Sharp et al. (1994) contradicted this finding showing a mean weight loss of 42% MPMW in males and 42.9% in females and speculated that this discrepancy might be attributed to males being premorbidly obese.

Crisp and Burns (1983) noted that all 36 patients showed regular carbohydrate avoidance. In terms of dietary habits, they also noted that 39% of the group exhibited signs of bulimia, 33% practiced vomiting, 22% participated in purging and 25% showed anxiety over eating with others. Sharp et al. (1994) demonstrated similar statistics with all patients exhibiting the avoidance of fats and carbohydrate and a large number engaging in the practices of binging, vomiting and laxative abuse. They also found that males were more likely to binge than females (46% vs. 36%). Tanofsky, Wilfley, Spurrell, Welch, & Brownell (1997) further examined the high occurrence of binge eating disorder in males.Their studies compared a group of 21 men and 21 women and administered the Emotional Eating Scale (EES) as well as the SCID to assess comorbid psychiatric disturbances and the SCID II to assess personality disturbances. Tanofsky et al. (1997) found that males rated significantly higher EES scores, demonstrated more lifetime Axis I psychiatric disorders and had a greater incidence of lifetime substance-related disorders. They speculated that the greater history of comorbid psychiatric disorders may be caused by distress over the stigma of the problem being primarily a female disorder.

Psychological characteristics in anorectics have also been studied. Crisp and Burns (1983) reported 44% of their male patients to be overactive as a feature of their illness and they also noted that 42% were active in sports prior to onset. Margo (1987) stated that overactivity was the only statistically significant clinical difference in her study comparing male and female anorectic with 62% of the male group exhibiting overactivity and only 26% of the female group demonstrating such. Yates et al. (as cited in Andersen, 1986) argued that compulsive running may be an expression of anorexia nervosa in males. Although compulsive running may simply be a case of obsessive- compulsive disorder, there exists a significant correspondence between the two suggesting the need for further research. Also, depressed mood was found in high occurrence in both the male and female groups of anorectics and obsessional behavior occurred in more than half of the groups (Sharp et al., 1994).

Another characteristic of male anorexia nervosa includes decreased sexual interest and testosterone level. Beumont et al. (as cited in Crisp & Burns, 1983) recorded testosterone levels in their six patients during emaciation and noted a diminished testicular function while a return to normal body weight reflected normal levels of testosterone. With respect to low levels of testosterone being the male equivalent of the DSM-IV requirement of amenorrhea, Scott (1986) suggested that evidence shows the endocrine decrease in males is due partly to malnutrition but that in females it may be independent of weight loss and therefore a poor diagnostic requirement.


Causal factors of eating disorders
There exists a strong correlation between a family history of mental illness and eating disorders. 33% of the male group in the Sharp et al. (1994) study had a first degree relative with a psychiatric illness in comparison to 44% of the female group. Also noted in the study were parental marital difficulties in 33% of the male group and 40% of the female group. Adverse childhood experiences are prevalent in the development of eating disorders in males. Kinzel, Mangweth, Traweger, & Biebel (1997) conducted a study of the relationship between the two. 26.2% of the men reported a familial deficiency syndrome. Kinzel et al. (1997) reported high scores on the Eating Disorder Inventory (EDI) scale for those who has adverse family background and experienced severe physical abuse.

The divergent social learning processes of males and females provide a background to causal factors that lead to the development of eating disorders. Andersen and Holman (1997) suggested three following processes of such. First, cultural norms for thinness lead to different perceptions of desired body images. 70-80% of 6th grade females perceive the need to lose weight although not medically obese. On the other hand, males perceive the need to diet at a significantly higher body mass indexes (BMI) in which there are deemed clinically overweight . Second, females are exposed to 10 times as many advertisements and articles advocating thinness as the ideal. Media and society work together in creating this social norm. Lastly, males diet as a means to an end whereas in contrast females diet as an unquestioned social practice.

Andersen (1986) argued that being teased and criticized for lack of control in terms of obesity often led to dieting amongst males. He went on to state that alteration of body size and shape thereby improving self esteem is the strongest motivational factor for dieting exhibited by males. Other motivational factors suggested include a desire to become more attractive to the opposite sex, requests by superiors to lose weight in return for career advancement, medical reasons, and effort to deter the aging process.

Important issues regarding eating disorders
Are women at higher risk for eating disorders, and if so, why? This has been a subject of much debate. Scott (1986) proposed that fewer males are at risk for anorexia nervosa because of their age at onset of puberty. Females develop physically before they develop emotionally and the stress on them puts them at high risk. He also suggested that males possess another safeguard that places them a lower risk, the lack of a sociocultural emphasis on thinness. Bardwick and Garner et al. (as cited in Scott, 1986) added the suggestion that males lack the modern female versus traditional women conflict which may lead to the females obsessive control over eating behavior and weight as a coping mechanism.

Several scholars have pondered the question of why few males are diagnosed with eating disorder cases. Scott (1986) cited four reasons for such. First, he suggested that clinicians saw very few instances of this disorder in males and therefore did not possess enough knowledge to make an accurate diagnosis. He mentioned Kesslers (as cited in Scott, 1986) idea that several clinicians sought the requirement of a notion of fear of oral impregnation before confirming a diagnosis of anorexia nervosa thereby excluding the male populations. He also suggested the exclusion of males by the diagnostic criteria of amenorrhea and lastly made note of the suggestion by Selveni (as cited in Scott, 1986) that eating behavior is secondary to other psychiatric disorders in male patients. There has also been the suggestion that male anorectics were masked by their athletic involvement (Crisps, Burns, & Bhat, 1986).

Sexuality of male patients has undergone much scrutiny. Crisp and Burns (1983) emphasized the relief and indifference to a decreased sexual drive felt by the male patients in contrast to the ambivalence toward menstruation by females. Two of their patients feared their homosexuality and diminished sexual interest eased their fears. Andersen (1986) suggested that adolescent males are limited in their sexual experience and which presents a source of distress.

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