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Males Assessed by a Specialized Adult Eating

Disorders Service: Patterns Over Time
and Comparisons with Females

Eric Button, PhD1* ABSTRACT

Objective: In view of previous inconsis-
a change in presentation rate by gender
over time. Males were more likely to be
Sarah Aldridge1 tencies and the limited literature on diagnosed as not having a clinical eating
Robert Palmer, FRCPsych1,2 males with eating disorders, we aimed to disorder and less likely to abuse laxa-
examine changes in presentation rates tives, but otherwise there was little differ-
over time and any differences between ence in clinical presentation.
males and females.
Conclusion: Eating disorders continue
Method: In a cohort of 2,554 new to present predominantly in females
patients assessed by a specialized service and the proportion of males remains
for adults over a 21-year period, we exam- broadly stable. V
C 2008 by Wiley Periodi-

ined rates by gender over time. We also car- cals, Inc.

ried out a detailed comparison of selected
clinical and demographic variables on a se- Keywords: males; gender differences;
ries of 65 males and females matched by incidence of eating disorders
diagnosis and date of assessment.

Results: Approximately 5% of patients

were male and there was no evidence of (Int J Eat Disord 2008; 41:758–761)

Introduction The incidence of eating disorders in females has

been extensively studied in both anorexia nervosa
The epidemiology of eating disorders has been
and bulimia nervosa. Some studies suggest an
extensively investigated in both clinical and com-
increase in incidence of anorexia nervosa over vari-
munity populations and there is a consensus that
ous time periods,2–6 whereas others report an
the two main disorders, anorexia nervosa and buli-
increase in incidence followed by a stabilization.7,8
mia nervosa, arise mainly in late adolescent girls
In the case of bulimia nervosa, there was a large
and young adult women. However, the existence of
increase in recognition during the 1980s, but in a
males with eating disorders has been recognized
review of epidemiological studies Fombonne9 con-
since the earliest descriptions and Andersen1 cites
troversially argued that there was no clear evidence
apparent case reports of what later came to be
of a rise in incidence. Thus there is still room for
known as anorexia nervosas as long ago as the 17th
debate with regard to the epidemiological findings
century. Moreover, Andersen1 suggested that eating
in females. Not surprisingly there is much more
disorders may be increasing in males, at least in
uncertainty with regard to males.
industrialized countries. Is there empirical evi-
dence for such an increase? And what are the char- The few studies of males show inconsistent find-
acteristics of eating disorders in males? ings with regard to incidence rates over time. Jones
et al.10 utilized the Monroe County Psychiatric
Register and nonpsychiatric medical records in a
study of 55 patients diagnosed with anorexia nerv-
Accepted 17 March 2008 osa in New York between 1960 and 1976. They
*Correspondence to: Dr. Eric Button, Eating Disorders Service, looked at male patients specifically and found fewer
Brandon Mental Health Unit, Leicester General Hospital, Leicester
males were diagnosed between 1970 and 1976 than
LE5 4PW, United Kingdom. E-mail:
Eating Disorders Service, Leicestershire Partnership NHS Trust, in the 1960s. In contrast, Braun et al.11 assessed
Leicester, United Kingdom consecutive nonrepeat admissions [including ano-
Department of Health Sciences, University of Leicester, Leices- rexia nervosa, bulimia nervosa and eating disorder
ter, United Kingdom
not otherwise specified (‘‘EDNOS’’)] between 1984
Published online 4 June 2008 in Wiley InterScience
( DOI: 10.1002/eat.20553 and 1996 to the eating disorders unit of The New
C 2008 Wiley Periodicals, Inc.
V York Hospital-Cornell Medical Centre. The overall

758 International Journal of Eating Disorders 41:8 758–761 2008


proportion of males was 6.7% and they found a 2. To explore whether there were any clinical or
significant increase in male admissions during the demographic differences between males and
study period. Bramon-Bosch et al.12 also examined females assessed by the Service.
referrals to a specialized eating disorders clinic
between 1996 and 1998 and reported that 11% were
male, across eating disorder diagnoses. Two studies
(Currin et al.13 and van Son et al.14) have reported Method
on time trends in incidence of eating disorders
derived from large scale monitoring of trends in Electronic records, clinic diaries, and selected case
primary care. Between 1994 and 2000 Currin et al.13 files were searched for the period 1987–2007. We aimed
found that 7.7% of new cases of anorexia nervosa to identify all ‘‘local’’ patients, both male and female,
and 5.3% of bulimia nervosa were male, with no assessed during this period. ‘‘Local’’ patients were those
evidence of a change over time. Van Son et al.,14 with a current home address (thus including students) in
however, only found 2% of males in both anorexia the counties of Leicestershire or Rutland, defined as
nervosa and bulimia nervosa between 1995 and those with a postcode beginning with the letters ‘‘LE.’’
1999. The overall pattern of the above studies thus We excluded referrals from outside this area in view of
points more toward stability rather than an the fact that they would be more likely to contain a pre-
increase in incidence in males over time. ponderance of more severe low weight anorexia nervosa
A recent large scale American study of the preva- as tertiary referrals. Our analysis was also restricted to
lence of eating disorders in both males and females the patient’s first episode of care with the service, thus
in the community15 found evidence of an increase excluding re-referrals. A total of 2,554 patients met the
in prevalence of bulimia nervosa and binge eating above criteria and this series was used to study numbers
disorder over time, but not for anorexia nervosa. of male patients over time.
Although they found a surprisingly high proportion Our electronic database contains relatively detailed in-
of men with anorexia nervosa and bulimia nervosa formation on clinical and demographic variables only for
they did not report on any differential effect those assessed from 1997 onwards. Moreover, at the time
between males and females over time. of writing, detailed clinical assessments were not com-
Some studies have compared males and females plete for 2007. We therefore decided to restrict our com-
in terms of clinical and other characteristics. Of parison of males and females to patients assessed
particular interest is the study by Bramon-Bosch between January 1, 1997 and December 31, 2006 (n 5
et al.12 who undertook a detailed comparison of 24 1,477). This included a detailed comparison of selected
males and 24 females, who had been assessed at clinical and demographic variables on a series of 65
The Maudsley Hospital London and were matched males and 65 females matched by diagnosis and date of
in terms of diagnosis and time of assessment. They assessment. The control was selected as the person
found male and female patients were similar across assessed most closely in time to the index patient and
diagnosis and clinical characteristics and this is a sharing the same diagnosis.
finding which is widely supported by other stud- Clinical variables included body mass index (BMI) at
ies.16–19 Several studies12,17,19 have reported higher initial assessment and symptom ratings based upon the
psychiatric comorbidity in males and a later age of Clinical Eating Disorders Rating Instrument (Palmer
onset has also been reported for males.12,16 Com- et al.20), which is a standard tool used in the service’s
parisons in terms of specific eating behaviors and assessment process. Statistical analysis utilized SPSS and
psychosocial characteristics, however, have pro- included both v2 and t-tests. This research was reviewed
duced more inconsistent findings. and approved by the Eating Disorders Service’s Research

Aims of Study
In view of the above inconsistencies and relative
paucity of data on males, we considered that the Results
database of the Leicestershire Adult Eating Disor-
ders Service provided an opportunity to explore Numbers of Patients Over Time
further this issue across the whole spectrum of eat- During the 21-year period between 1987 and
ing disorders. We had two main aims: 2007, we identified a total of 2,554 new ‘‘local’’
patients assessed by the service. Of these, 128
1. To examine any change over time in presenta- (5.0%) were male and 2,426 (95.0%) were female.
tion rates of males. We examined rates per year for both male and

International Journal of Eating Disorders 41:8 758–761 2008 759


FIGURE 1. Percentage of males presenting over time. TABLE 1. Diagnosis by gender

Male Male Female Female
Diagnosis (n) (percent of total) (n) (percent of total)

Anorexia nervosa 8 10.7 175 13.4

Bulimia nervosa 16 21.3 364 27.9
EDNOS 35 46.7 639 49.0
No eating disorder 16 21.3 127 9.7
All diagnoses 75 100.0 1305 100.0

TABLE 2. Comparison of 65 matched males and females

on clinical and demographic variables
Male Female
Variablea % % v2 Significance

Eating restraint 41.3 49.2 3.790 .741

Fasting 14.1 12.7 2.008 .734
female patients and the summary percentage fig- Vomiting 33.8 27.0 1.970 .734
ures for males are displayed in Figure 1. Laxatives 6.2 10.8 14.921 .005
Exercise 26.2 28.6 3.375 .497
It can be seen that there was no clear trend over Other compensatory behavior 5.0 1.8 8.065 .089
time. Although there were larger numbers of Binge eating 32.3 34.4 1.702 .790
patients of both sexes seen in the second decade, Occupational status (full-time 74.6 60.7 8.823 .357
there was no significant difference in the propor- Educational level 36.1 39.3 4.697 .583
tion of males between the two decadesa (v2 5 (‘‘A’’ level or above)
0.429, d.f. 1, n.s). Moreover, the absolute number of Civil status (%single) 79.7 60.7 14.740 .012
Living situation 73.0 36.7 29.262 \.0001
new ‘‘local’’ males presenting remained virtually (alone/with parents)
constant during the last 6 year of the study. a
For eating behavior, all percentages refer to the behavior occurring at
least weekly.
Clinical and Demographic Comparison
between Males and Females In terms of demographic variables, males were
We were able to compare both age and diagnosis both more likely to be single (v2 5 14.740, d.f 5, p 5
on 1,380 patients (75 male and 1,305 female) 0.012) and also to be living with their family of ori-
assessed between 1997 and 2006. There was no sig- gin (v2 5 29.262, d.f 8, p \ .0001).
nificant difference in age, but there was a signifi-
cant difference in the distribution of diagnosis by
gender (v2 5 10.814, d.f. 3, p \ .02), as displayed in
Table 1.
There were proportionately slightly fewer males The main aim of our study was to investigate any
with both anorexia nervosa and bulimia nervosa, changes over time in the presentation of males to a
but the biggest difference was in the proportion of specialized eating disorders service for adults. We
males with no eating disorders (21.3%), which was found that over a 21-year period the proportion of
over double that for females (9.7%). new male patients from the local area ranged
Out of those 76 males assessed between 1997 between 1% and 9%, but there was no clear trend
and 2006, we were able to obtain sufficient clinical over time. On average the proportion of males was
detail and suitable female matches on 65 patients. 5%. This figure is within the range of 5–10% typi-
These data are summarized in Table 2. cally reported in other studies and is not too dis-
The only significant clinical difference here was similar from large-scale general practice survey of
that males were less likely to regularly abuse laxa- Currin et al.13 This was also conducted in the UK
tives (v2 5 14.921, d.f. 4, p 5 0.005). Moreover, only and they found males to represent 5.3% of bulimia
12.3% of males had ever used laxatives for weight nervosa and 7.7% of anorexia nervosa.
control versus 38.5% for females. There was no dif- Our findings confirm that eating disorders con-
ference in BMI. tinue to predominantly affect females and give no
support to the idea that the incidence of eating dis-
orders in adult males is increasing. However, this
interpretation needs to recognize that our data are
This calculation covers the decades 1987–1996 and 1997–2006. of men presenting to services and may not repre-

760 International Journal of Eating Disorders 41:8 758–761 2008


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