The relative rarity of anorexia nervosa in the male might lead one to surmise that the disorder is likely to differ between the sexes in its aetiology, clinical manifestations, and prognosis. The first study that examined this premise in a sizeable series of male patients found remarkable similarities between the sexes as regards the age of onset and the specific features of the psychopathology. (104) For example, the male patients tended to select a diet which was low in fattening foods and resorted to subterfuges to dispose of food, such as self-induced vomiting and purging, and strenuous exercising. They expressed a fear of fatness and considered themselves overweight, even when they were thin. Other investigators were also struck by these surprising similarities. (105)
Of course there are fundamental biological differences which inevitably alter the manifestations of the endocrine disorder in the male and, to a lesser extent, the nutritional disorder. Testicular function, as gauged by the urinary output of testosterone, is disturbed in male patients when they are emaciated. Refeeding leads to at least a partial correction of this abnormality. (104) The body composition of the mature male differs from that in the female; he has a lower reserve of adipose tissue so that protein depletion occurs more rapidly when he loses weight.
The relative resistance of the male against developing anorexia nervosa remains a mystery. It is even unclear whether the sex difference is likely to be due to biomedical factors or psychosocial differences. It has been suggested that young females often become preoccupied with 'fatness' because of its reproductive, biological, and social significance, whereas young males are more concerned with their musculature and its significance for strength, dominance, and masculinity. (105) These differences are linked with the frequency of dieting among adolescent girls and its rarity in boys. (106)
In a series of male patients with 'primary' anorexia nervosa most of the patients reported problems with sexuality. (1°Z) Sexual anxieties had been present with respect to heterosexual as well as homosexual behaviour. One quarter had had homosexual contacts or admitted homosexual tendencies. Almost all were relieved by the loss of libido following weight loss. The authors concluded that males with atypical gender role behaviour had an increased risk for developing anorexia nervosa in adolescence.
There are only a few follow-up studies of anorexia nervosa in males. In the best study available, 27 patients were followed up for a minimum of 2 years and a mean of
8 years/l06,) Expressed in the terms of the Morgan-Russell categories of general outcome, a good outcome was found in 44 per cent, an intermediate outcome in 26 per cent, a poor outcome in 30 per cent, and no deaths. Only a few predictors of outcome were identified: disturbed relationships with a parent in childhood led to a poor outcome, and the occurrence of previous sexual activity was associated with a good outcome. The outcome in males was remarkably similar to that in females.(106)
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