Anorexia Nervosa in Males: Similarities and Differences to Anorexia Nervosa in Females

Previous single case reports of males with anorexia nervosa from our database focused on the roles of gender and general personal identity conflicts and panic/guilt over the consequences of impulsivity in precipitating out the illness (Davis & Crisp, 1993; Fry & Crisp, 1989; Toms & Crisp, 1972), the growth stunting but reversible effects of early onset (Toms & Crisp, 1972), and a 35-year long follow-up of a case first seen in 1959 (Crisp, 1995). Our first reported series of 13 male patients (Crisp & Toms, 1972) drew attention to the many similarities to a female population but emphasised, descriptively, the high prevalence of psychiatric morbidity in the parents, often bound in with phobic avoidance behaviours and commonly coupled with over-protectiveness of the patient during childhood. A study of the hormonal status of 12 male patients as their body weights were restored to normal levels (Crisp, Hsu, Chen, & Wheeler 1982; Wheeler, Crisp, Hsu, & Chen 1983) revealed that, as with females, at a low weight there was no LH response to releasing hormone stimulation. As weight was gained to the high 40 kgs range, LH responses were enhanced. On reaching target weights (over 60 kgs) the response tended to normalise. Meanwhile, testosterone levels rose linearly in relation to weight gained. The important psychotherapeutic implications of the accompanying psychopathological changes driven by these somatic changes were highlighted. Subsequent clinical reports on 36 male patients, included a comparative study with a series of 100 female cases (Crisp, Burns, & Bhat, 1986) and a follow-up study of 27 of them for a mean length of eight years (Burns & Crisp 1984). These studies again revealed many similarities between male and female cases, e.g. only minor differences in social class background, mean ages of onset and presentation, degree of premorbid overweight. Dietary patterns were also generally similar except that the females more frequently ingested large quantities of laxatives. With parents, weight disorders were even more common than within the female series. Thus, within the 105 females low body weight of anorectic proportions was present in 14 mothers, nine fathers and seven siblings. Three of the mothers had current anorexia nervosa. Major obesity was present in 10 instances, most often the mother. So far as the 36 males were concerned, one father and four mothers were recorded as having had definite anorexia nervosa; this was also the case for a number of siblings. Ten of the fathers and seven of the mothers were markedly obese. In one family both parents had had definite anorexia nervosa. The follow-up studies revealed somewhat different predictors of outcome between the sexes. For males, absence of premorbid sexual activity boded ill. Moreover, greater impulsivity, including bulimia/vomiting within the illness, was not predictive of poor outcome, in contrast to the females. Thus, whilst the ascetic female anorectic did better, in the long term, than her impulse ridden counterpart, this was not so in the male series. In the male series, gender identity doubt, sometimes coupled with panic recognised as being due to potential impulsivity, seemed to remain a major precipitating factor, with the anorectic regression to pre-puberty forging the defence. However, it could be that such ‘gender doubt’ was also a common, though sometimes less emphasised, premorbid feature in the female anorectic. More recently, and related to other studies of patterns within the illness over the last 35 years (see this