Diagnosis of Male Anorexia Nervosa: Gender Bias?

Why does the fourth diagnostic criterion focus solely on females?

Posted Nov 29, 2012

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the bible of psychiatric disorders, specifies four essential features of anorexia nervosa. The first is refusal to maintain body weight appropriate to age and height. The second is an intense fear of gaining weight or becoming fat. The third is disturbance in the way one’s body weight and shape are experienced. The fourth criterion is amenorrhea, or the absence of at least three consecutive menstrual cycles, in females who have reached puberty.

This fourth criterion has been criticized for its gender bias (Soban, 2006). Although amenorrhea is a useful physiological sign that supports the diagnosis of AN in women and postmenarchal girls, males do not experience a menstrual cycle. Without an equivalent criterion for males, clinicians may be less likely to consider the disorder in men and boys (Braun, 1997). In fact, the biggest roadblock to diagnosing AN in males may be that clinicians don’t consider the possibility (Andersen, 1990).

Because hormone function in males is easily obtained, some researchers have argued that a male equivalent for amenorrhea should be provided in diagnostic criteria (Andersen, 1990; Braun, 1997). Men and boys with AN experience considerable endocrine disturbance, which is similar to the dysfunction behind amenorrhea in females (Herzog, Bradburn, & Newman, 1990). Decline in the levels of testosterone production, in particular, have been documented in numerous studies (e.g., Crisp, Hsu, Chen, & Wheeler, 2006; Lemaire et al., 2006). And testosterone levels are easily measured.

As a sidenote, in many studies subjects' testosterone levels remain significantly lower than normal even after weight restoration. As a result, some researchers conclude that factors other than malnutrition must account for continued low testosterone levels in males with AN (Lemaire et al., 1983). Further research is needed to determine why. One possibility, however, is that males continue unhealthy eating patterns even after regaining their target weights.


American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed) (text revision) (DSM-IV-TR). Washington,DC:American Psychiatric Association.

Andersen, A. E. (1990). Diagnosis and treatment of males with eating disorders. In A. E. Andersen (Ed.), Males with eating disorders (pp. 133-162). New York: Brunner/Mazel, Inc.

Braun, D. (1997).Eating disorders in males. Medscape Mental Health, 2(4). Retrieved on August 11th 2008 from http://www.medscape.com/viewarticle/431281.

Crisp, A.H., Hsu, L.K.G., Chen, C.N., & Wheeler, M. (2006). Reproductive hormone profiles in male anorexia nervosa before, during and after restoration of body weight to normal: A study of twelve patients. International Journal of Eating Disorders, 1(3), 3-9.

Herzog, D.B., Bradburn, I.S., & Newman, K. (1990). Sexuality in males with eating disorders. In A. E. Andersen (Ed.), Males with eating disorders (pp. 40-53). New York: Brunner/Mazel.

Lemaire, A., Ardaens, K., Lepretre, J., Racadot, A., Buvat-Herbaut, M., Buvat, J. (2006). Gonadal hormones in male anorexia nervosa. International Journal of Eating Disorders, 2(4), 135-144.

Soban, C. (2006). What about the boys? Addressing issues of masculinity within male anorexia nervosa in a feminist therapeutic environment. International Journal of Men’s Health.