Eating Disorders in Adolescent Males

Author(s): Shannon L. Ray

Source: Professional School Counseling , OCTOBER 2004, Vol. 8, No. 1 (OCTOBER 2004),
pp. 98-101
Published by: Sage Publications, Inc.

Stable URL: https://www.jstor.org/stable/42732420

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 Shannon L. Ray, Ph.D.,
LMHC, is graduate
associate faculty ,
University of Central
Florida , Orlando.

Eating Disorders in Adolescent

Males
to 12 times that of the typical adolescent popula-
Research indicates that the primary onset of eating
disorders occurs in adolescence and that there is a
tion - appropriate early identification and early diag-
growing prevalence of adolescent males with eating nosis are imperative (Reijonen et al.). The likelihood
disorders . In this article we describe the eating disor-of higher than reported prevalence rates of males
ders of anorexia nervosa and bulimia nervosa as they with eating disorders, in conjunction with the peak
relate to adolescent males. Diagnostic criteria , at-riskage of onset occurring in adolescence, underscores
groups, and implications for school counselors are eachthe importance of the school counselor's knowledge
base in identifying eating disorders in male students.
discussed. The importance of the school counselor's role
in identification, referral, psychoeducation, and sup- This article provides diagnostic descriptions of the
port services for this population is critical. risk factors and etiology of eating disorders in the
adolescent male population. A discussion of sub-
populations that present with heightened risk factors
awareness of eating disorders has increased, ensues. In addition, implications for school coun-
In although
althoughawareness
eating disorders
the pasthave
eatingbeenseveral
reported
of eating
for disorders decades, disorders have professional been has reported and increased, public for selors are included that provide information to assist
hundreds of years (Reijonen, Pratt, Patel, & the school counselor with his or her role in provid-
Greydanus, 2003). Commonly perceived to be a ing appropriate referrals, psychoeducational infor-
female affliction, it is ironic that the first document- mation, and support services. School counselors
ed clinical case of anorexia was in a male; additional- with an awareness of prevalence rates and etiology of
ly, males comprise between 10% to 15% of the eating eating disorders in adolescent males can successfully
disordered population (Johnson & Connors, 1987; provide front-line assistance to these males in both
Keel, Klump, Leon, & Fulkerson, 1998; Russell & at-risk and diagnostic groups (Felker & Stivers,
Keel, 2002; Walcott, Pratt, & Patel, 2003). Specific 1994; Fischer et al., 1995; Nelson & Hughes, 1999;
prevalence rates among males are difficult to deter- Patel, Pratt et al., 2003).
mine and may be higher than reported due to the
hidden nature of eating disorders and the perception DESCRIPTION
that eating disorders are found solely in females
(American Psychiatric Association, 2000; Keel et al.; The Diagnostic and Statistical Manual of Mental
Patel, Pratt, & Greydanus, 2003; Reijonen et al.; Disorders (4th ed. text rev., American Psychiatric
Scheider, 1991). The societal stigma surrounding Association, 2000) describes the criterion for the
eating disorders is one of secrecy and shame; as a diagnosis of anorexia as the refusal to maintain a
result, eating disordered males often go to great normal bodyweight as defined by weight of less than
lengths to hide their condition (Patel, Pratt et al.; 85% of typical bodyweight for a given height as well
Scheider). as experiencing intense fear related to gaining
The primary age of onset of eating disorders, for weight. Young men comprise approximately 10% to
both males and females, falls between 12 and 26 15% of those suffering from the disorder; the peak
years with a peak onset age of 14 to 18 years age of onset for both genders falls between 14 and
(American Psychiatric Association, 2000; Phelps & 18 years. The negative health effects of the disease
Bajorek, 1991). One study examined prevalence include: metabolic changes, emaciation, constipa-
rates for school-age youth and posited that 9% to tion, thyroid difficulty, heart abnormalities, and
11% of all school-age youth met diagnostic criterion death (Reijonen et al., 2003). The mortality rate for
for eating disorders (cited in Reijonen et al., 2003). individuals with anorexia proves greater than any
Due to the debilitating side effects of eating disor- other mental disorder and has been shown to be as
ders - that include morbidity and mortality rates up high as 15% (American Psychiatric Association,

98 ASCA I PROFESSIONAL SCHOOL COUNSELING

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2000; Phelps & Bajorek, 1991; Reijonen et al.; ture, assessments that rely on self-report, and lack of
Scheider, 1991). This alarming statistic, in conjunc- uniform criteria across studies (Murphy & Gute-
tion with the primary age of onset occurring during kunst; Patel, Greydanus, et al.).
the middle and high school years, underscores the Nelson and Hughes (1999) examined the risk fac-
importance of the school counselor's role in appro- tors of developing an eating disorder and also assert-
priate identification and understanding of the risk ed that male athletes display increased susceptibility.
factors of anorexia. This proves especially true in sports where body size
According to the DSM-IV-TR (2000), individuals and proportion remain under intense scrutiny.
suffering from bulimia eat a large amount of food in Nelson and Hughes discussed the elevated incidents
a limited time period, experience a lack of control of anorexia and bulimia in their male sample popu-
over eating during that time, engage in inappropri- lation and also suggested the likelihood of higher
ate purging behavior, display maladaptive eating pat- prevalence rates than previously suspected. They
terns at least two times per week for 3 months, and reported that there is minimal research literature
are hypersensitive to weight fluctuations. Purging addressing eating disorders in males and discussed
methods include: vomiting, laxative use, excessive the need for future research endeavors in this area.
exercise, or subsequent restricted food intake. Patel, Greydanus, et al. (2003) investigated preva-
Unlike those suffering from anorexia, individuals lence rates for adolescent athletes and concurred
with bulimia are often of normal body weight and with previous studies that posited the underestima-
are better able to hide their disease. The currently tion of incidents in the male athletic population. Pa-
reported prevalence rates represent 1% to 3% of the tel, Greydanus, et al. specifically emphasized young
The mortality rate
population in industrialized countries; however, men in sports that focus on body weight and body
actual rates may be considerably higher as the accu- image - wrestling, swimming, track, rowing, and for individuals with
racy of these statistics remains suspect due to under- gymnastics. The pressure that these athletes put on
reporting (American Psychiatric Association, 2000; themselves leads them to engage in maladaptive eat-
anorexia proves
Keel et al., 1998; Patel, Pratt et al., 2003; Reijonen ing behaviors that prove dangerous to their physical
et al., 2003; Scheider, 1991). Like anorexia, the typ- health such as: excessive exercise, caloric and fluid
greater than any
ical range of onset for both genders occurs in the restriction, laxative and diuretic use, self-induced
adolescent years (American Psychiatric Association; other mental
vomiting, and starvation (Patel, Greydanus, et al.).
Lyon & Chatoor, 1997; Reijonen et al.). Diving, bodybuilding, gymnastics, and running
represent additional sports that hold increased disorder
risk and has
AT-RISK GROUPS for the development of eating disorders. In these
sports, the impact of body image is emphasized, been
the shown to be as
athletes are judged to some degree by physical
There are several sub-populations of adolescent
appearance, and to be competitive they often de-
males that present with heightened risk factors. high as 15 percent.
Adolescent males more at risk for developing mand extremely low percentages of body fat (Mur-
eating
phy & Gutekunst, 1997; Oliosi, Dalle Grave, &
disorders include those involved in athletic activities,
Burlini, 1999; Patel, Greydanus, et al., 2003). The
struggling with sexual identity conflict, diagnosed
with co-morbid mental disorders, or with a belief
familyof some athletes is that competing in a lower
weight
history of eating disorders and a chaotic home division or reducing their body fat index will
envi-
ronment. Knowledge regarding the heightenedincrease
risk their chances of winning. Both coaches and
athletes
factors for this population proves important, espe- tend to adopt this belief system to succeed.
Ironically, the deleterious side effects of anorexia or
cially since early identification of eating disorders
improves treatment outcomes (Reijonen et al.,bulimia
2003).often hinder their performance due to the
health risks of disordered eating patterns that physi-
Athletes cally weaken the athletes and lead to decreased per-
formance (Murphy & Gutekunst). Clearly, the
Eating disorders occur to a greater degree in athletes
than in the general population (Murphy & demands placed on athletes to achieve and maintain
Gutekunst, 1997; Patel, Greydanus, Pratt, & a certain body weight put them at heightened risk
Phillips, 2003). Adolescent athletes in sports with for the development of eating disorders.
weight classifications and those engaging in activities
where lean body types are preferred are at the high-Sexual Identity
est risk for developing eating disorders (Patel,The relationship between sexual identity and eating
Greydanus, et al.). Assessing the percentage of maledisorders remains unclear; however, several studies
athletes suffering from either anorexia or bulimiaposit that male homosexuals are at increased risk for
proves even more difficult than in the general popu-developing eating disorders (Buroughs &
lation due to a myriad of factors that include:Thompson, 2001; Walcott et al., 2003). Sexual iso-
methodological limitations from the current litera-lation, sexual inactivity, and disturbed sexual identi-

8:1 OCTOBER 2004 | ASCA 99

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 fication have also been linked to the clinical popula- both subjective and objective accounts (American
tion of eating disordered males. Buroughs and Psychiatric Association, 2000; Nassar & Hodges,
Thompson examined the sexual orientation of 1992). School counselors aware of the link between
anorexic and bulimic males and found that the eating disorders and the diagnoses enumerated in
this section will have relevant information to assist
prevalence of homosexuality in the sample popula-
them with accurate identification of students at risk.
tion was significantly higher than that of the general
male population. The authors suggested that one
Family Issues
possible explanation for their findings was the sub-
version of sexual conflict resulting from the sideMale adolescents who have a history of eating disor-
ders in their family are at greater risk for the devel-
effect of decreased libido. Additionally, homosexual
males may be more at risk for the development of opment of anorexia and bulimia (American
eating disorders due to a heightened emphasis on Psychiatric Association, 2000; Felker & Stivers,
physical attractiveness (Walcott et al.). 1994; Manley et al., 2000; Pratt, Pratt et al., 2003).
Manley, Rickson, and Standeven (2000) reported Additionally, family environments that are tumul-
tuous
that boys present with anorexia at a significantly have been linked to decreased treatment effec-
higher percentage than adult males, although theytiveness for eating disorders (Felker & Stivers;
Male athletes point out that the reasons for the growing preva-Manley et al.). Any recent intrafamilial loss such as
lence in boys remains unclear. They comment on death or divorce has also been identified as a risk fac-
display increased this possibly resulting from burgeoning sexual con-tor. Finally, adolescent males in households where
appearance and body image are emphasized remain
flict emerging in the adolescent period. The lack of
susceptibility, knowledge regarding the sexual characteristics ofat heightened risk for developing an eating disorder
boys and men with eating disorders underscores the (Manley et al.).
especially in sports need for further research (Scheider, 1991; Walcott
IMPLICATIONS FOR SCHOOL
et al., 2003). Knowledge of the existing research in
where body size COUNSELORS
this area can benefit school counselors by providing
them with an awareness of the additional risk that
and proportion homosexual youth may face for the development ofSchool counselors can play a critical role in assisting
an eating disorder. This knowledge assists the schoolmale students either at-risk or currently battling an
remain under counselor with identification and represents the first eating disorder (Manley et al., 2000; Russell & Keel,
step in the treatment process. 2002). The following is a list of guidelines that will
intense scrutiny - benefit school counselors in their work with adoles-
Mental Disorders cent males:
wrestling, Co-morbid mental disorders that may provide warn-
1. School counselors need to know the risk factors
ing signs for adolescent males at risk for the devel-
swimming, track, opment of an eating disorder include: Mood specific to adolescent males. These can be
Disorders, Substance Abuse and Dependence, and remembered as the "six red flags" of
rowing, and Personality Disorders (American Psychiatric 1 Age 14 to 18 years
Association, 2000). Specifically, a plethora of i Athletes in sports that focus on body image and
gymnastics. research studies displayed a predisposition to eatingweight classifications
disorders among those diagnosed with depression1 Homosexuality or confusion related to sexual
(e.g., Fischer et al., 1995; Lyon & Chatoor, 1997;identification
Moreno & Thelen, 1995; Nassar & Hodges, 1992; 1 Any occurrence of the previously enumerated
Pratt, Phillips, Greydanus, Pratt, & Patel, 2003;mental disorders that appear co-morbid with
Pryor & Weiderman, 1998). eating disorders
1 Recent turmoil in the home environment that
Features of Obsessive Compulsive Disorder are
- could trigger the onset of an eating disorder
frequently seen in individuals suffering from anorex-
ia and bulimia. The obsessive-compulsive behaviors such as death of a loved one, divorce, moving,
focus on food, body image, and weight. Also, and financial difficulties
impulse control issues remain prevalent in males
1 Presence of family members suffering from an
with bulimia; this links with Substance Abuse and eating disorder as well as a family environment
Cluster B Personality Disorders such as Borderline,that stresses physical appearance and body image
Histrionic, and Narcissistic as individuals with these
diagnoses also display poor impulse control 2. School counselors should be aware of resources
(American Psychiatric Association, 2000). available in the community. This represents iden-
As with Personality Disorders and Mood tification of referral agencies and practitioners
Disorders, low self-esteem is often reported in eating who have experience working with this popula-
disordered clients. This has been demonstrated in tion. The school counselor's role in initiating

100 ASCA I PROFESSIONAL SCHOOL COUNSELING

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 bance and eating disorders in males. International
appropriate community referral would include
Journal of Eating Disorders, 3 1 (3), 307-3 1 1 .
providing the student and his family with general
Felker, K., & Stivers, C. (1 994). The relationship of gender and
information on community psychotherapeutic family environment to eating disorder risk in adoles-
resources as well as emphasizing the importance cents. Adolescence, 29, 82 1 -835.
of a medical evaluation to assess the general phys- Fischer, M., Golden, N., Katzman, D., Kreipe, R., Rees, J.,
ical health of the client. The research has shown Schebendach, J., et al. (1 995). Eating disorders in adoles-
cence Journal of Adolescent Health, 16, 420-437.
that treatment for eating disorders can encom-
Johnson, C., & Connors, M. (1 987). The etiology and treatment of
pass months of individual and group therapeutic bulimia nervosa: A biopsychosocial perspective. New York:
interventions; this underscores the need for the Basic Books.
school counselor to be aware of available com- Keel, R, Klump, K., Leon, G., & Fulkerson, J. (1 998). Disordered

munity resources (Manley et al., 2000; Phillips, eating in adolescent males from a school-based sample.
International Journal of Eating Disorders, 23, 1 25-1 32.
Greydanus, Pratt, & Patel, 2003).
Lyon, M., & Chatoor, I. (1 997). Testing the hypothesis of the
multidimensional model of anorexia nervosa in adoles-
3. School counselors can educate parents, teachers, cents. Adolescence, 32, 101-112.
coaches, and community members on the follow- Manley, R., Rickson, S., & Standeven, B. (2000). Children and

ing: awareness of the signs and symptoms of eat-adolescents with eating disorders: Strategies for school
counselors. Intervention in School and Clinic, 35, 228-232.
ing disorders, prevalence rates in males, and each
Moreno, A., & Thelen, M. (1 995). Eating behavior in junior high
of the risk factors previously discussed. School school females. Adolescence, 30, 1714-1728.
counselors possess a critical knowledge base that
The relationship
Murphy, S., & Gutekunst, L. (1 997). Disordered eating among
can be incorporated into parent education pro- athletes: The athletic trainer's role. Washington, DC:
Human Kinetics. between sexual
grams and parent/teacher association presenta-
Nassar, C., & Hodges, P. (1 992). Self-concept, eating attitudes,
tions (Manley et al., 2000).
and dietary patterns in young adolescent girls. Sc/ioo/
identity and eating
Counselor, 39, 338-344.
4. School counselors may monitor their students'
Nelson, W.,& Hughes, M. (1999). Anorexic eating attitudes and
disorders remains
progress in referred treatment as well as provide at-behaviors of male and female college students.
Adolescence, 34, 62 1 -644.
school support for those students in outpatient
Oliosi, M., Dalle Grave, R., & Burlini, S. (1 999). Eating attitudes in unclear; however,
counseling. School counselors can also assist by of-
noncompetitive male body builders. International
fering group counseling opportunities for at-riskJournal of Eating Disorders, 7, 227-233.
several studies posit
or diagnosed male students (Phillips et al., 2003).
Patel, D. R., Greydanus, D. E., Pratt, H. D., & Phillips, E. L. (2003).
Eating disorders in adolescent ath letes Journal of
Adolescent Research, 18, 280-296. that male
SUMMARY
Patel, D. R., Pratt, H. D., & Greydanus, D. E. (2003). Treatment of
adolescents with anorexia nervosa .Journal of Adolescent homosexuals are at
The importance of understanding the etiology of Research, 18, 244-260.
eating disorders in males cannot be denied, especial-
Phelps, L., & Bajorek, E. (1 991 ). Eating disorders of the adoles-
increased risk for
cent: Current issues in etiology, assessment, and treat-
ly when considering their deleterious effects on both
ment. School Psychology Review, 20, 9-23.
mental and physical health (American Psychiatric
Phillips, E. L., Greydanus, D. E., Pratt, H. D., & Patel, D. R. (2003). developing eating
Association, 2000; Reijonen et al., 2003). The insid-Treatment of bulimia nervosa: Psychological and psy-
ious nature of these illnesses - secrecy, shame, phys-
chopharmacologic considerations .Journal of Adolescent disorders
ical health problems, and heightened mortality
Research, 18, 261-279.
Pratt,
rates - engenders a professional responsibility inH. D., Phillips, E. L., Greydanus, D. E., Pratt, H. D., & Patel, D.

school counselors (Fisher et al., 1995; Nelson R.

& (2003). Eating disorders in the adolescent population:
Future directions. Journal of Adolescent Research, 18,
Hughes, 1999; Patel, Pratt et al., 2003). School
297-313.
counselors can provide important services toPryor,T.,
stu- & Weiderman, M. (1 998). Personality features and
dents, parents, teachers, coaches, and community expressed concerns of adolescents with eating disorders.
members that include: identification, referral, psy-Adolescence, 33, 292-302.
Reijonen, J. H., Pratt, H. D., Patel, D. R., & Greydanus, D. E (2003).
choeducation, and at-school support services. Due
Eating disorders in the adolescent population: An
to their direct contact with students in the peak overview. Journal of Adolescent Research, 18, 209-222.
modal age group, school counselors remain in the C. J., & Keel, P. (2002) Homosexuality as a specific risk
Russell,
position to play an active role in the battle against
factor for eating disorders in men. International Journal
eating disorders in the adolescent male population. of Eating
I Disorders, 3 1 (3), 300-306.
Scheider, J. A.(1991). Gender identity issues in male bulimia
nervosa. In C Johnson (Ed.), Psychodynamic treatment of
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