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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] 1 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. 2 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 3 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: 4 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 5 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 6 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, 7 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 8 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: 9 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, 10 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. 11 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. 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