While it's known that one in 10 persons with eating disorders is a man, the link between males and eating disorder still eludes the medical community. Boys with the same symptoms as anorexic girls are less often diagnosed. Warren says check lists tailored to women and girls are often used to diagnose men and boys. Questions like "Do you worry about the size of your buttocks? Do you worry about your thighs?" aren't suited to men.
If a dozen men at a gym, who take supplements, follow fad diets and lift weights for hours, took a screening test with these types of questions, no matter how sick they were, they might still pass, Warren says.
The first reported case of anorexia in a male may have been documented by Dr. Richard Morton in the late 17th century. Morton described the disease in this particular case as "a total want of appetite occasioned by studying too hard and the passion of his mind."
His treatment plan was simple. "I advised him to abandon his studies, to go into the country air and to use riding and a Milk Diet for a long time," John Morgan, author of "The Invisible Man: The Self-Help Guide for Men with Eating Disorders, Compulsive exercise and Bigorexia", quoted Morton as having written.
As Freudian psychoanalysis emerged in the late 19th century, the male anorexic, along with most male psychiatric disorders, disappeared. Freudians held that anorexia was caused by "a fear of oral pregnancy." This, for obvious reasons, prevented any male diagnoses.
"Men weren't even allowed to have anorexia until the 1980s," says Warren of the Cleveland Center for Eating Disorders. In the 1980s, Arnold Anderson, a professor of psychiatry at the University of Iowa, re-introduced the concept of male anorexia. Men with anorexia share many of the same symptoms as women: excessive dieting, distorted body image and compulsive exercise, according to the National Eating Disorder Association.
Today, most people still believe that anorexia is caused by poor parenting or vanity, Warren says. But that isn't true, he notes. "Unless you're born with a vulnerable neurobiology, you can't get an eating disorder," he says. Genes don't definitively predict who gets an eating disorder, they simply predispose a person to developing one. But it's impossible to get one without them, he says.
Dr. Andersen researched and wrote several books on eating disorders in men. Dr. Philip Mehler, a medical director at the ACUTE Center for Eating Disorders in Denver, and Andersen together authored "Eating Disorders A Guide to Medical Care and Complications."
When comparing the impact of the disease in men and women, the balance seems mostly even. "Whatever females develop, males develop," Mehler says. He listed heart problems, digestion problems, neurological problems, changes in blood chemistry and severe problems swallowing that can lead to a certain type of pneumonia. Men sometimes experience decreased libido and testosterone levels and erectile dysfunction. Some men's voices change.
If patients don't die from starvation, from the re-feeding process, from cardiac problems or from suicide,(anorexia is often linked with depression) the greatest long-term risk is osteoporosis.
"Osteoporosis in anorexia is one of the rare complications that may not be reversible," Mehler says.
According to his research, the loss of bone density in men is more severe in anorexic males than in females, and the the consequences are serious. "If you're a 25 year old male who develops anorexia and you get over it, you may have horrible bone disease and lose height and have compression factors and pain in your back for the next 50 years of your adult life."
Mehler also cited evidence of long-term cognitive deficits. "We know that on CAT scans the volume of the brain shrinks during anorexia. It's not clear that that all comes back to where it was." A Harvard math professor, for example, might not operate on the same plane as before his illness, Mehler says, even if he is pronounced fully recovered.