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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
Anorexia Nervosa – The Female Phenomenon:
Repositioning the Males
Derek Botha
Department of Development Studies
Nelson Mandela Metropolitan University
South Africa
Contact:
Derek Botha
c/o Nelson Mandela Metropolitan University
South Africa
[email protected]
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
Abstract
Discourses on anorexia nervosa have ranged from its origins in religious practices of
female self-starvation, to the presently constituted female phenomenon informed by
psycho-medical ideas. These discourses have created the dominant understandings
and knowledge of anorexia nervosa, a milieu that males enter whilst dealing with
anorexia nervosa. These taken-for-granted discourses have led to difficulties in
diagnostic practices with males, and have consequently impacted on the reported low
prevalence of males with anorexia nervosa. Furthermore, past research has drawn on
the dominant positivist/empirical, quantitative approaches, and has tended to exclude
males, or has included a significantly lesser number of males than females in research
samples. In these cases, the process of ‘generalisation’ of findings has raised doubts
as to the validity of the findings in regard to the male population. In addition, until
very recently, there has been a conspicuous lack of qualitative research exploring the
experiences of users of treatment for eating disorders. These circumstances offer an
opportunity to undertake qualitative research, using narrative analysis, to assist in
understanding the experiences specifically of males with anorexia nervosa - a problem
that is understood, diagnosed and treated as a female phenomenon.
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
1 - Introduction
This article considers specific circumstances of members of a
marginalised community. More particularly, it is concerned with the
marginalised status of a gendered group as far as it is associated with a
dominant phenomenon that society has constructed and understands in the
other gendered group. The article looks at the significant lack of research and
knowledges in regard to males with anorexia nervosa. This community of
males has a complicated positioning, and occupies a site of contradictory
discourses, a site of power differentials that create socially constructed
dominant ‘truths’ about anorexia nervosa, a site in which males with anorexia
nervosa have been significantly neglected, dishonoured, overlooked,
excluded and ignored.
Anorexia nervosa constitutes a major health care problem (Becker,
Grinspoon, Klibanski & Herzog: 1999), and has been described as one of the
most common chronic illnesses among young females today (Touyz &
Beumont: 2001). Not only has the history of ‘anorexia nervosa’ been
documented with an overwhelmingly female prevalence, but there has also
been an emphasis on females in current psycho-medical research on
etiologies of anorexia nervosa, Western world diagnostic criteria, and matters
relating to treatments.
There is no efficacious psychotherapeutic treatment approach for
anorexia nervosa (Bulik, Berkman, Brownley, Sedway & Lohr: 2007; Finelli:
2001). In fact, research has indicated that results for the treatment of
anorexia nervosa have been less than favourable (for example, Bergh,
Brodin, Lindberg & Sodersten: 2002), that there have been limited successes
for treatments (Bulik et al.: 2007; Eckert, Halmi, Marchi, Grove & Crosby:
1995), and that persons dealing with anorexia nervosa have indicated low
levels of satisfaction with treatment (Crowe: 2000; Newton, Robinson &
Hartley: 1993). Furthermore, research undertakings have embraced anorexia
nervosa as a female phenomenon where males have been marginalized
and/or neglected (Bulik et al.: 2007; Carlat, Carmago & Herzog: 1997;
Crosscope-Happel: 1999; Kinzl, Mangweth, Traweger & Biebl: 1997;
Steinhausen: 2002).
Given these circumstances, the article argues for a more considered
approach to males dealing with the problems of anorexia nervosa. It submits
that, in the light of the discourses that constitute the taken-for-granted
feminine knowledges relating to anorexia nervosa, it may be appropriate to
explore how males construct their subjectivities through the diagnostic
process as well as the treatment experiences. The article is presented in
three interrelated sections.
Firstly, it briefly explores the evolutionary process of the nature and
knowledges of the phenomenon that today is referred to as anorexia nervosa.
This phenomenon was originally constituted by early religious discourses of
female self-starving practices, and then by the clustering of knowledges of
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
anorexia nervosa into an essentially psycho-medical notion of a female
condition. These explorations are undertaken to contribute to some
understanding of the taken-for-granted dominant historical and cultural
discourses that have been drawn on in the construction of the notion of
anorexia nervosa. They present the historical, cultural and socially
constructed nature of anorexia nervosa as a feminine phenomenon that males
are confronted with when struggling with anorexia nervosa.
Secondly, this article examines important factors relating to research
activities, and to the main problems that have contributed to the reported
relatively low prevalence of anorexia nervosa in males.
Finally, this article submits that these circumstances present an
opportunity to initiate qualitative research that could assist in understanding
the experiences of males who are attempting to deal with anorexia nervosa in
an environment where anorexia nervosa is understood to be, is researched
as, has diagnostic biases towards, and whose treatment approaches have
tended to embrace it as a female phenomenon.
This article does not attempt to provide an academic scrutiny of
minutiae for definitive accounts of issues raised in regard to anorexia nervosa.
It aims to paint broad landscapes in order to construct and reflect fundamental
understandings of the evolution of the discourses that have constituted
anorexia nervosa as essentially a female phenomenon, as well as the impact
thereof on the significant lack of information relating to experiences of males
dealing with anorexia nervosa.
In addition, in view of the fact that the referenced literature is reflective
of dominant ideas from Western society, the nature of anorexia nervosa in this
article is seen through these lenses. Other cultural notions of self-starvation
practices from non-western countries and communities are thus excluded.
2 - A synopsis of the primary discourses that have informed knowledge of,
and about anorexia nervosa
Section 2 consists of a brief discussion of the historical and culturally
contextual ways in which anorexia nervosa has been understood and socially
constructed.
2.1 - Self-starvation: some early religious discourses
Some of the earliest practices of self-starvation drew on Western
Christianity for explanations and interpretations of the nature of the
relationship between females and food (Hepworth: 1999). As far back as the
12th century females who starved themselves were held in high esteem, and,
due to their fasting, were deemed to be saints by male clerics (Hepworth:
1999).
This practice of self-starvation was undertaken in an intensely passive
relationship with male clerics whose approval was necessary for it (Hepworth:
1999). The early relationships between females and holiness, and females
and thinness were conceptualized as representing the ideal states of being in
a struggle to assert female identity in a world dominated by men (Cohn:
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
1986). During the 12th to 15th centuries, there were few cases of male saints
who claimed, or were claimed by others, to be capable of undertaking the
practice of self-starvation (Brumberg: 1988).
2.2 - Self-starvation: the shift from religious to the psycho-medical influence
In later medieval years there were shifts in religious interpretations of
self-starving females. These shifts were mainly resultant upon the differences
that self-starving females exhibited compared to the social norms of the
period, where, socially and ideologically, females constituted the ‘Other’ males were the norm against which females were evaluated and their actions
defined. And in this context, religious beliefs developed into sophisticated
sets of arguments that defined femininity in binary terms of good or evil
(Hepworth: 1999). Such shifts away from sainthood, led to the Church
articulating an interpretation of these self-starving females as deviant,
immoral, evil (Lock, Agras, Bryson & Kraemer: 2004), manipulative and
deceitful (Ehrenreich & English: 1979), and self-starvation became an
indication of an unnatural and sinister existence. This interpretive change in
the practice of self-starvation of females continued throughout the middle
ages, with the witch-hunts of the 15th and 16th centuries being the most
extreme example of the effects of the religious interpretation of females as the
‘Other’ (Hepworth: 1999).
By the sixteenth century, the words ‘wise woman’ and ‘witch’ became
interchangeable, especially in Scotland (Scot: 1584, cited in Thomas: 1971).
‘Wise women’ were healers, herbalists, and were sometimes called ‘blessing
witches’ (Ehrenreich & English, 1979:35). By this stage, many men viewed
witchcraft as the ‘…single greatest threat to Christian European civilization’
(Kors & Peters, 1972:5). The first fully articulated theory of witchcraft and the
start of massive persecution did not appear until the end of the fifteen century
with the publication of the Malleus Maleficarum, written by two Dominican
Inquisitors who explicitly identified witchcraft with women (cited in Kors &
Peters: 1972). The Inquisitors claimed that women were witches because
they were more subject to the wiles of the devil than men; this was because
they were more impressionable, credulous, feebler in mind and body, and
more carnal. Their intellect was claimed to be different from men’s, and they
were defective and always deceived (Kors & Peters, 1972:114-127). The
Inquisitors concluded: ‘Blessed be the Most High who has so far preserved
the male sex from a great crime’ (Kors & Peters, 1972:127).
Socio-cultural changes that constituted witchcraft as a female social
evil, later ushered in the notion of ‘hysteria’ that was soon broadened to
characterize the essential nature of females as being ‘irrational’ (Hepworth:
1999; Lock et al.: 2004). With the shift from the religious to a more
‘psychological’ orientation and framework of reference, self-starvation came to
be understood as a form of hysteria, and indicative of a ‘disordered mind’. In
this context, Faure wrote that ‘What had hitherto been attributed solely to the
action of the devil was now attributed to a sickness’ (1981). Thus, the 17th
and 18th centuries saw further cultural revisions in the understanding of the
practice of self-starvation that culminated in the transition of the
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
understanding of self-starving females from the status of sainthood, to that of
patient-hood.
The transition from religious to psycho-medical formulations of selfstarvation reflected the significant changes in the discursive constructions of
self-starvation, as ‘scientific’ theories and rationalizations began to take the
place of theological discourses. By the end of the eighteenth century, new
medical knowledges had emerged which ‘...escaped ecclesiastical institutions
without being truly independent of the thematics of sin’ (Foucault, 1971:116).
These historical and cultural shifts into the scientific paradigm brought
about the ‘discovery’ of the illness that then became referred to as ‘anorexia
nervosa’, as opposed to the former construct of ‘self-starvation’. The first
published texts (Gull: 1868; Gull:1874; Lasegue: 1873a; Lasegue: 1873b) that
reported cases on the original ‘discovery’ of anorexia nervosa were essentially
anecdotal in nature. It is important to note that Gull’s presentations (1868;
1874) emphasised the female gender-specific nature of anorexia nervosa
(although, in the 1868 report, Gull conceded that anorexia nervosa could
occur in males, but he had not seen any cases).
The submissions from Gull (1868; 1874) that anorexia nervosa was a
psycho-medicalised feminine phenomenon, formed the basis of the
developing etiology of anorexia nervosa that was influential due to the
emergent scientific and medical context within which it was discussed (for
instance, in leading medical journals such as The Lancet), and to the
respected status of the two male physicians who contributed to its ‘discovery’.
The nineteenth century saw ‘anorexia nervosa’ introduced as an
overwhelmingly female condition (Ehrenreich & English: 1979) that became
increasingly presented through psycho-medicalised understandings. In other
words, the medical milieu in which anorexia nervosa emerged was one where
the socio-historical affinity between females and pathology was particularly
apparent (Brumberg: 1982; Malson: 1998). By the close of the nineteenth
century ‘anorexia nervosa’ had become an established object of medical
discourse with a female pathology.
From the turn of the nineteenth century until the 1930s, there were
significantly few reports about anorexia nervosa. The period between 1930s
and mid 1960s saw a rising scientific underpinning of psychiatric practices,
and research reports regarding anorexia nervosa re-emerged in medical and
psychiatric literature. Throughout these decades, authors emphasized that
the diagnosis of anorexia nervosa was specific to females, overwhelmingly
young females (Hepworth: 1999; see, for instance, Bruch: 1974; Nemiah:
1950; Nemiah: 1958).
Through the 1970s, and up to the late 1980s, scientific medical
literature continued to dominate the explanation and treatment of anorexia
nervosa through psychiatric practice. However, social theorists, psychologists
and feminist writers (Chernin: 1986; MacLeod: 1981; Orbach: 1978; Orbach:
1986) began to introduce several different theories and rationalisations about
the etiology of anorexia nervosa (Malson: 1998). Feminist writers drew
attention to the distress that females experienced in relation to eating and
psychological health. They submitted that one reason was that it was a form
of female social protest that challenged the social, political and economic
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
inequalities between males and females (Malson: 1998). The writings of the
feminists introduced a notion of anorexia nervosa that drew directly on
females’ experiences of themselves and social relationships. In particular,
these writers expressed the interrelationships between females’ experiences
of living in Western societies, the effects of a subordinated social position, and
the denial of food by females (Malson: 1998).
Changing cultural trends in female body shape in the late twentieth
century were also an explanation of why females strove to be and remain thin.
The rise in the impact of the mass media created a portrayal of the ideal
feminine body as one that was characterized by thinness. These feminine
based cultural developments have also been fundamental to socio-cultural
discourses in attempts to explain the onset of anorexia nervosa (Malson:
1998; Wooley & Wooley: 1982).
Socio-cultural research has thus indicated the prominence of the
idealisation of the thin female body (Silverstein, Peterson & Perdue: 1986),
the prevalence of body-dissatisfaction (Wardle, Bindra, Fairclough &
Westcombe: 1993), dieting (Woolf: 1990), and weight- (Russell: 1986) and
food-related concerns amongst Western women (Malson: 1998). In this
context, anorexia nervosa has functioned as an expression of societal
concerns with personal display, feminist politics, the fashion for dieting,
normative thinness and slimness (Bordo: 1990; Brumberg: 1988; Malson:
1998).
The discussion so far has considered discourses that have contributed
towards the explications of how anorexia nervosa has been constructed as a
feminine phenomenon. The purpose has been to establish the nature and
thrust of the taken-for-granted dominant historical and cultural discourses that
have constituted the phenomenon of anorexia nervosa as a female
phenomenon over time, and more recently, of anorexia nervosa as a psychomedicalised feminine condition. These have been the constructions that have
been drawn upon to create the dominant understandings and knowledges of
anorexia nervosa, a milieu that males enter and are confronted with whilst
dealing with anorexia nervosa.
2.3 - Anorexia nervosa: comments on current diagnostic issues and males
The identification of definitive causes of anorexia nervosa has eluded
scientific studies for over a hundred years. However, there exist a number of
etiological rationalisations and theories of its onset, such as genetic, affective,
cognitive, systemic, bio-psychological, psychodynamic, feminist, and sociocultural (Grothaus: 1998; Hepworth: 1999; Malson: 1998; Malson & Ussher:
1996). It is relevant for the purposes of this article to mention that the vast
majority of studies have dealt with the formulation of etiological
rationalizations as a female condition; specific etiological theories for males
are not presented, although attempts have been made to formulate general
differences in etiology between male and female conditions (Andersen: 1990).
During the second half of the twentieth century the diagnostic
categories for anorexia nervosa changed considerably. In fact, in the mid
twentieth century virtually no official research criteria existed for studies on
anorexia nervosa. The first research criteria appeared in 1972 (Feighner,
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
Robins, Guze, Woodruff, Winokur & Munoz: 1972). This was followed by
diagnostic criteria as outlined in the third edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III: American Psychiatric
Association: 1980), the third revised edition (DSM-III-R: American Psychiatric
Association: 1987) the fourth edition (DSM-IV: American Psychiatric
Association: 1994) the fourth, ‘text revised’ edition (DSM-IV-TR: American
Psychiatric Association: 2000), as well as the 10th revision of the World Health
Organisation’s International Classification of Mental and Behavioural
Disorders (Clinical Descriptions and Diagnostic Guidelines - ICD-10: 1992).
The diagnostic criteria for anorexia nervosa in DSM-III-R, DSM-IV, and DSMIV-TR are practically the same, while the diagnostic criteria in the DSM-IV-TR
correlate with ICD-10. Although there are definite core parallels between
DSM-IV and ICD-10, the strict imposition of DSM versus ICD criteria could
lead to the identification of slightly different populations.
In this context, it is of interest to note that the standard set of Western
world diagnostic criteria for anorexia nervosa since 1987 (that is, the various
versions of the DSM since DSM-III-R) has effectively excluded males by
listing amenorrhea as one of the four requirements - men and boys,
technically, by definition, are amenorrheac. Although males do not
experience amenorrhea, they can experience endocrine disturbances when
they engage in self-starvation and excessive exercise. In fact, ICD-10
specifically provides an alternative to amenorrhea for males - ‘…in women,
amenorrhea, in males, loss of sexual interest and potency…’ (ICD-10, code
F50.0, 138-139). This endocrine disturbance encountered in males manifests
as a general decline in the levels of testosterone production which results in
diminished sexual desire and performance (Carlat et al.: 1997; Herzog,
Bradburn, & Newman: 1990; Russell & Beardwood: 1970). As a result of the
decline in testosterone levels, resulting in males experiencing diminished
sexual desire and interest, it may be that males could be reluctant to admit to
such conditions. This response could also impact upon the reported low
prevalence of anorexia nervosa in males. In this context, some researchers
have also remarked on a cognate symptom to use in diagnosing men, for
whom ‘decreased sexual drive and performance’ is considered an ‘equivalent’
for amenorrhea (Muise, Stein & Arbess: 2003; Wabitsch, Ballauff, Holl, Blum,
Heinze, Remschmidt, & Nebebrand: 2001; see also Andersen: 1995; Tomova
& Kumanov: 1999). These stipulations do not specify what kinds of sexual
desire and erotic encounter count in measuring to what degree such
experiences have decreased (Anderson: 2008). Reading sexual drive and
performance in men as equivalent to menstruation in women writes into
diagnostic technologies for men a more expansive and different story of
sexual and reproductive normality.
Hepworth (1999) has indicated that diagnosing males with anorexia
nervosa has become obscured by medical, psychological, historical, social
and cultural interpretations and portrayals of females as the gender group
who are primarily affected by the condition. In other words, the long-standing
position of anorexia nervosa as primarily a female condition, and its
relationships with a discourse of femininity may have created a reluctance to
diagnose the condition in males (Hepworth: 1999). Maleness may be a
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
barrier to both the disclosure and the possible diagnoses of anorexia nervosa
in males. Hepworth and Griffin have suggested that anorexia nervosa may be
more common among males than is realized ‘…because of the discursive
structure through which anorexia is represented as a typically female
condition’ (1995:74).
Hepworth (1999) has also contended that the process of diagnosing
anorexia nervosa in a male becomes a discursive process that tends to draw
on related issues such as psychiatric co-morbidity, severity of weight loss,
problems with self-disclosure, and clinicians’ questioning because the
dominant explanation of anorexia nervosa specifically links it with an historical
and cultural ideology of femininity. She stated further that the narrative of
masculinity in relation to anorexia nervosa tended to accentuate the search
for different reasons for anorexia nervosa in males and females, and the need
for it to be diagnosed and/or treated differently (Hepworth: 1999).
3 - The research status:males and anorexia nervosa
Having explored the evolutionary processes and the historical and
cultural discourses that have contributed to the current understandings of
anorexia nervosa as an essentially psycho-medicalised female phenomenon,
this article moves on to examine how these dominant understandings have
impacted on the significant dearth of knowledge that prevails in regard to
males and anorexia nervosa. This examination will focus on the prevalence
of anorexia nervosa in males, and issues relating to the nature of published
research in regard to anorexia nervosa.
3.1 - Prevalence of anorexia nervosa in males
Estimating the incidence and demographic distribution of anorexia
nervosa is complex (Malson: 2000) because, for example, of the difficulties in
determining appropriate definitions of ‘caseness’ (Szmuckler, Eisler, Russell &
Dare: 1985); because of differences in referral practices for different sections
of populations (Wardle et al.: 1993); because different studies use different
assessment methods; and because of variations in the results of different
epistemological studies. Figures regarding the prevalence of anorexia
nervosa among males indicate that it is approximately between 10%
(Alexander-Mott: 1994; Andersen & DiDomenico: 1992; Braun, Sunday,
Huang & Halmi: 1999; Hoek, Bartelds, Bosveld, van der Graaf, Limpens,
Maiwald & Spaaij: 1995), to 15% (Andersen: 1995) as common as it is in
females. Crisp (1996) believes this is too high; rather, he contends that it is
closer to 2% at the most.
One main reason for varying estimates may be due to the diagnostic
criteria for anorexia nervosa in the DSM-IV-TR, as one of the criteria used to
diagnose anorexia nervosa is the presence of amenorrhea. While the
collective criteria may be adequate for diagnosing females, the DSM-IV-TR
does not clearly identify symptomology that is present in males only - in other
words there are no analogous criteria for males (Andersen: 1992; Andersen:
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
1999). Research has suggested that the criteria in the DSM-IV-TR for
anorexia nervosa are gender-biased, and account for many mental health and
medical practitioners incorrectly diagnosing, or under-diagnosing anorexia
nervosa in the male population (Crosscope-Happel, Hutchins, Getz & Hayes:
2000). Another factor that could influence the diagnostic predicament could be
the approaches that have been adopted to anorexia nervosa in males,
compared with females (Woodside, Garner, Rocket & Garfinkel: 1990), where
some researchers have proposed psychological theories that suggest that
anorexia nervosa could not exist in males (Burns & Crisp: 1984; Cobb: 1943;
Crisp & Burns: 1990; Nemiah: 1950; Selvini-Palazzoli: 1965). In fact,
physicians as well as males who are struggling with the effects of anorexia
nervosa, are often unaware that anorexia nervosa could occur in both
genders (Goodman, Blinder, Chaitin & Hagman: 1988). Furthermore,
whereas the attraction and obsession with the notion of ‘thinness’ is socially
accepted as a ‘normal’ cultural attitude with females, the preoccupation with
his body by a male is seen as an abnormal identification with the feminine
(McVittie, Cavers & Hepworth: 2005).
Crosscope-Happel has stated ‘...anorexia nervosa in males is a
growing problem that continues to be ignored and misunderstood by many in
academic, mental health, and medical professions’ (1999:69), and that
‘...anorexia nervosa in males is under-diagnosed primarily because most
professionals believe that it is exclusively a female disorder’ (1999:69).
3.2 - Nature of research on anorexia nervosa
In spite of diverse etiologies, explanations and theories, anorexia
nervosa has been almost invariably conceptualised and dealt with as an
internalised, individualised, clinical entity (Botha: 2009; Gremillion: 1994;
Hepworth: 1999; Malson: 1998; Malson, Finn, Treasure, Clarke, & Anderson:
2004; Malson & Ussher: 1996). Consequently quantitative research based on
notions of positivism and empiricism has focused mainly on examining
causes, clinical features and prognoses, and on assessing treatment in terms
of outcomes.
This study was unable to trace relevant reported research that covered
the period from the turn of the nineteenth century until the 1960’s that
focussed specifically on males and anorexia nervosa. This study then
focused on an examination of more recent published research on anorexia
nervosa. This examination indicated that there have been attempts to include
references to males and anorexia nervosa in the more recent studies. These
studies have continued to be based on the traditional forms of modernist,
structuralist quantitative approaches (see, Bassett: 2002; Crosscope-Happel
et al.: 2000; McVittie, Cavers, Hepworth: 2005).
In examining recent published research results on anorexia nervosa it
is important to note the manner in which gender representation in research
samples has been dealt with. What tends to dominate, are studies that:

do not indicate the gender composition of the research sample (see, for
example, Bergh et al.: 2002; Button & Warren: 2001;); or,
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.

use research samples that comprise females only (see, for example,
Bulik, Sullivan & Joyce: 1999; Channon, Da Silva, Hemsley & Perkins,
1989: Crisp, Norton, Gowers, Halek, Bowyer, Yeldham, Levett, & Bhat:
1991; Eivors, Button, Warner & Turner: 2003; Eckert et al.; 1995; Geist,
Heinmaa, Stephens, Davis & Katzman: 2000; Loewe, Zipfel,
Bucchholz, Dupont, Reas & Herzog: 2001; McIntosh, Jordan, Carter,
Luty, McKenzie, Bulik, Frampton & Joyce: 2005; Pike, Walsh, Vitousek,
Wilson & Bauer: 2003; Von Holle, Pinheiro, Thornton, Klump, Berrettini
et al.: 2008), or,

do indicate the proportionate inclusion of females and males in the
research sample - this prevails in a relatively few studies where the
number of males is usually considerably less than the female
component (see for example, Crisp, Gowers, Joughlin, McClelland,
Rooney et al.: 2006; Dare, Eisler, Russell, Treasure & Lodge: 2001;
Eisler, Dare, Hodes, Russell, Dodge & Le Grange: 2000; Gowers,
Clark, Roberts, Griffiths et al.: 2007; Herpertz-Dahlman, Muller,
Perpertz, Heussen, Hebebrand & Remschmidt: 2001; Lock, Agras,
Bryson & Kraemer; 2005; Treasure, Todd, Brolly, Tiller, Nehmed &
Denman: 1995; Waller, Mugan, Morshed, Setnick, Cummings & Hynan:
2003). Although the gender composition of the sample of participants
is given in the studies, the important fact is that the research analyses
invariably fails to separate for males and females. In the conclusion of
their systematic reviews of randomised controlled trials, Bulik et al.,
(2007) indicated that males were underrepresented, and that, when
included, their numbers were usually too small to be analysed
separately or compared to females.
There are concerns that arise with the above ways of representation of
gender in research samples of reported studies. Before indicating these
concerns, it is essential to note the nature of the research approaches that
dominate recent studies on anorexia nervosa. A significant factor is that the
numerous etiological rationalizations and theories of anorexia nervosa have
been informed mainly by modernist ideas of structuralism (Kant: 1781; Kant:
1788; Kant: 1790; Cushman: 1995). These ideas are reflected in
epistemological positions of positivism and/or empiricism, which are
essentially constructs of the scientific model that have been embraced and
applied in the medical, psychiatric and psychological fields. This prominence
of positivism and/or empiricism toward the attempts at understanding anorexia
nervosa is reflected in a predominant emphasis in research activities on
quantitative approaches. One of the main features of quantitative forms of
research is that a sample from the identified population is used for the
analysis. The assumption is that a statistically appropriate sample would be
significantly representative of a population (that is, the sample would include
all the features which might be of interest from the population). The analyses
of the research results, using the sample, would then permit generalisations
about the population based on the frequency and regularity of phenomena
reflected in the sample.
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Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
These comments in regard to the process of ‘generalisation’ that is a
focal point of quantitative research, need to be related to the gender
representation of the studies examined for this article, most of which have
been referenced above (when denoting the tendencies in regard to the gender
structures thereof). Given the function of the process of ‘generalisation’ in
quantitative research context, it would be questionable to generalise to the
male population, the findings from studies using female-only samples. In
addition, it would be problematic to generalise the findings to males where the
study indicates the inclusion of both genders and the proportionate
representation (invariably with an insignificant number of males in the
sample), but where the analyses fails to separate for males and females.
Again, those studies with undifferentiated gender samples would be of little
relevance and value for a contribution to knowledge about males struggling
with anorexia nervosa because of the questionable applicability of the
‘generalisation’ principle.
As indicated earlier, the emphases on the positivist/empirical,
quantitative paradigm for research on anorexia nervosa has resulted in a
predominant focus on clinical features and prognoses, and on assessing
treatment outcomes and the efficacies of treatments. There has been a
conspicuous lack of research that explores the experiences of those
diagnosed with anorexia nervosa, and/or the users of treatment for anorexia
nervosa using qualitative research. Interest in qualitative discourse research
has, however, already illustrated how medical, psychiatric and psychological
discourses inform and regulate knowledges and treatment of ‘mental illness’
and its subjects (Foucault: 1971; Foucault: 1977; Parker, Georgaca, Harper,
McLaughlin & Stowell-Smith: 1995), and specific types of diagnoses
(Stoppard: 2000; Swann: 1997).
Qualitative analyses have been undertaken of both bulimia nervosa
and anorexia nervosa as discursively constituted diagnostic categories of
‘eating disordered’ subjectivities and body management practices (Bordo,
1992: Bordo: 1993; Crowe: 2000; Malson: 1998; Malson: 1999; Malson: 2000;
Malson & Ussher: 1996). Researchers have begun to use discourse analysis
to explore patients’ accounts of treatment for eating disorders (Malson et al.:
2004), and nurses’ accounts of nursing ‘eating disordered patients’ (Ryan,
Malson, Clarke, Anderson & Kohn: 2006). More relevant for this article have
been qualitative discourse studies that have focused on the narratives that
have reflected the inpatient treatment experiences specifically of adolescent
females with anorexia nervosa (Boughtwood: 2006; Halse, Honey,
Boughtwood: 2008; Segal: 2003). In spite of reported research embracing
studies on eating disorders informed by qualitative approaches, there remains
an acute paucity of relevant and meaningful research specifically on males
with anorexia nervosa.
4 - Concluding comments and suggestions
In order to situate the feminine emphasis for the purposes of this
article, some historical discourses of self-starvation and of anorexia nervosa
12
Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
were presented in a chronological landscape of events. This was not aimed
at any type of formal historical analysis, nor was it in any way meant to be a
submission of a doctrine of final causes. Its purpose was to contextualise the
historical evolution of what was originally called self-starvation as a feminine
condition, as well as to trace and note the shift of influence from that of
religious discourses to the current scientific discourses of knowledges of
anorexia nervosa as a psycho-medicalised feminine condition.
Research studies, using mainly quantitative methodologies, have
significantly favoured and dealt with females as the prime, if not sole subjects
of the psycho-medicalised constructed object, namely, anorexia nervosa. In
consequence, the issue of males and anorexia nervosa, and research on that
location, has been significantly marginalized.
It is therefore suggested that there is a clear and vital need for
additional research that could make an important contribution to particular
knowledges about males and anorexia nervosa. For this purpose a number of
options are available. As an initial approach to this suggested additional
research, it may be opportune to undertake a qualitative study to examine the
experiences of males who are diagnosed with anorexia nervosa, and/or their
experiences of treatment (Botha: 2009). Such alternatives are suggested as,
for instance, there may be males who are medically ‘diagnosed’ with anorexia
nervosa, but who do not accept such a ‘diagnosis’ and reject invitations to
subject themselves to current treatment practices that are of limited efficacy,
or there may be males who have not been medically ‘diagnosed’ with
anorexia nervosa, but, who, may however, allow themselves to be subjected
to some form of treatment processes for ‘anorexia nervosa’ (for females’
approaches on these issues, see, Boughtwood: 2006; Halse et al: 2008).
When addressing relevant issues with these males, qualitative
research, incorporating notions of critical theory, can be a constructive
methodology for examining the numerous ways in which power relations and
taken-for-granted normative cultural values are embedded in the discursive
constructs of diagnoses and/or treatment of anorexia nervosa. Narrative
analysis, using experience-centred narratives (Squire: 2008), would be an
appropriate research method, drawing on a Foucauldian approach to narrative
work (Tamboukou: 1999; Tamboukou: 2003; Tamboukou: 2008). A
Foucauldian approach is proposed as it would enable an examination of the
discursive worlds that these males inhabit, and enable the tracing of possible
ways of being that are afforded to them, and how they constitute their
subjectivities when dealing with the psycho-medicalised feminine
phenomenon of anorexia nervosa. In other words, it would aim to produce
knowledge about the discursive environment within which the males then find
themselves, and what it means for them as human subjects (for their sense of
self, for their experiences), and how their subjectivities are constructed. Such
an approach could provide ways of understanding the specific experiences
and the processes of the constitution of subjectivities of males, given that they
are attempting to deal with a problem that has been, and currently still is
considered, researched and dealt with as a feminine phenomenon.
The nature of the discourses explored in this article seem to
underscore in a significant way that, as anorexia nervosa is much more
13
Botha, D. (2010). Anorexia Nervosa – The Female Phenomenon: Repositioning the Males.
Counselling, Psychotherapy, and Health, 6(1), 1-20.
common in the lives of females than in the lives of males, gender-related
discourses could contribute to influencing conditions that may be favourable
when exploring experiences of anorexia nervosa. The suggested experiencecentred research approach, using Foucauldian narrative analysis, may
provide spaces for hearing previously dishonoured, dismissed disregarded, or
other discourses that have previously been granted diminished social
accreditation. Such explorations may provide understandings that could
suggest ways that discourses of gender could be similar in the ways in which
anorexia nervosa operates in the lives and relationships of males and
females. On the other hand, experience-centred narrative research may
indicate differences in the way the ‘voice’ of anorexia nervosa frames its
arguments to males, which may, at times, lead to them experiencing
‘anorexic’ practices that are different from those experienced by females. In
other words, the deconstructive nature of experience-centred narrative
analysis could suggest in what ways anorexia nervosa was using discourses
of masculinity and/or femininity for its own purposes. Gender differences and
similarities in the experiences of anorexia nervosa would provide fertile
grounds for reconsidering etiologies of anorexia nervosa for males, and for
the possibilities to consider alternative, and hopefully more efficacious and
efficient ways of interventions and treatment for males with anorexia nervosa.
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