Beyond the Drive for Thinness: Clinical Characteristics and Diagnostic Red Flags in Male Pediatric Eating Disorders: A Case Series

Beyond the Drive for Thinness: Clinical Characteristics and Diagnostic Red Flags in Male Pediatric Eating Disorders: A Case Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond the Drive for Thinness: Clinical Characteristics and Diagnostic Red Flags in Male Pediatric Eating Disorders: A Case Series Ruth Arias-Hidalgo, Covadonga Canga-Espina, Azucena Díez-Suárez This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9428669/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : Eating disorders (EDs) are severe psychiatric illnesses associated with high morbidity and mortality. Traditionally, their strong association with the female gender has resulted in a scarcity of literature regarding male presentations. This disparity leads to limited clinical understanding, diagnostic delays, and a lack of gender-specific therapeutic guidance for the male population.. Description of the clinical cases : We present a series of five clinical cases of male children and adolescents (under 18 years old) diagnosed with EDs and treated at our Child and Adolescent Psychiatry Outpatient Unit between 2022 and 2023. The cases highlight diverse presentations, ranging from severe restrictive Anorexia Nervosa with life-threatening malnutrition to exercise-focused compensatory behaviors and body dissatisfaction centered on muscularity.. Discussion : While sharing core features with female presentations, EDs in males exhibit distinct patterns, such as a drive for muscularity ("inverted anorexia"), compulsive physical exercise as a primary compensatory mechanism, and the absence of traditional physiological markers like amenorrhea. These factors often mask the disorder, leading to misdiagnosis or late intervention.. Conclusions : Identifying male-specific "red flags"—including height/weight stagnation and obsessive exercise—is crucial for early detection. Further research is essential to develop gender-sensitive diagnostic tools and integrated treatment protocols to ensure high-quality, specialized care for this underserved population. Eating Disorders male Eating Disorders Anorexia Nervosa compulsive exercise muscle dysmorphia INTRODUCTION Eating disorders (EDs) are psychiatric illnesses associated with significant morbidity and mortality, as they are the leading cause of malnutrition in Western countries and rank among the mental illnesses with the highest rates of direct mortality. EDs are also among the psychiatric disorders most strongly associated with gender, with a lower prevalence observed in men; the female-to-male ratios are approximately 10:1 for Anorexia Nervosa (AN, ICD-11 6B80) and Bulimia Nervosa (BN, ICD-11 6B81), and 2:1 for Binge Eating Disorder (BED, ICD-11 6B82). This gender disparity has lead to a scarcity of literature on EDs in males, resulting in a limited understanding of the disorder and a lack of specific clinical guidance for this specific population (Gorrell & Murray, 2019 ) (Brown & Keel, 2023 ). To address this gap,we present a series of five clinical cases involving male patients under 18 years of age who attended our Child and Adolescent Psychiatry Outpatient Unit between 2022 and 2023. The study protocol was approved by the local Ethics Committee (project 2025.283). All data were de-identified to ensure patient confidentiality in accordance with the Declaration of Helsinki and Spanish Organic Law 3/2018, of December 5, on the Protection of Personal Data and the guarantee of digital rights, and its latest update in Law 11/2023, published on May 9, 2023 (previously replacing Directive 95/46/EC of the European Parliament and of the Council, of October 24, 1995, on the protection of natural persons with regard to the processing of personal data and on the free movement of such data). All patients who come to our clinic agree that their information may be used for medical or research purposes, as long as they cannot be identified through the same. CASE SERIES Case 1 Anamnesis and history of illness A 15-year-old male, only child, with no significant past medical history. Two years prior, he began to express concerns about his physical appearance and a desire to lose weight following negative peers’ comments about his body. This led to restrictive eating behaviors, increased physical activity, and progressive weight loss. Subsequently, he experienced loss of control over eating, followed by self-induced vomiting, initially suggested by a classmate. At onset, his height was 170 cm and his weight was 74 kg (Body Mass Indexz –BMI –: 25.6 kg/m²); through purging, he reduced his weight to 62 kg. During summer, his restrictive eating intensified, leading to severe anxiety around food exposure, as well as symptoms of sadness, lack of motivation, fatigue, feelings of worthlessness, low self-esteem, and guilt; associated with a three-month period of school absenteeism. Despite receiving care from a psychologist (not specialized in clinical psychology) and a nutritionist, his progress was minimal. Three months later, he presented at the Emergency Room with severe malnutrition, having lost 38% of his initial body weight. At that time, he denied ongoing purging behaviors but exhibited intense body dysmorphic symptoms, multiple cognitive distortions, and occasional passive thoughts of death. His mother acknowledged having a restrictive eating pattern herself, linked to her perimenopausal stage, and admitted to a certain preoccupation with body image. Family Psychiatric History : Father with anxiety symptoms, and mother with a history of altered eating behaviors, anxiety, and occasional dissociative episodes; however, neither had received specific treatment. Physical and psychopathological examination (dup: abstract ?) Weight : 46 kg, Height : 178 cm, BMI : 14.50 kg/m², Heart Rate : 33 bpm, Blood Pressure : 92/60 mmHg. The patient appeared severely malnourished, with psychomotor retardation, dry mucous membranes, hypotonia (barely able to hold up his head), and hypothermia. His facial expression was hypomimic, with avoidant eye contact, delayed response latency, and decreased attention span. Speech was minimizing and excessively accommodating, with apparent indifference, and marked feelings of inadequacy, worthlessness, and incapacity. His self-esteem was low, with persistent preoccupation around body image. He exhibited multiple cognitive distortions and overvalued ideas related to weight and nutrition, including a desire for increased muscle mass in the chest and arms, and a flat abdomen. Low mood with apathy, anhedonia, asthenia, emotional lability, and occasional irritability. He reported passive thoughts of death, without active suicidal ideation. Partial insight. Diagnosis and recommended treatment (dup: abstract ?) The patient was diagnosed with Anorexia Nervosa with significantly low body weight, restricting pattern (ICD-11 6B80.00) and a moderate depressive episode without psychotic symptoms (ICD-11 6A70.1), along with bradycardia. He was urgently admitted to the inpatient unit, where he remained for 70 days, followed by a 10-day admission to the Day Hospital. Upon discharge, his weight was 61 kg (BMI: 18.9), showing improvement in his overall condition and resolution of bradycardia (see Fig. 1 for progress). He required electrocardiographic monitoring and nighttime enteral nutrition in addition to an oral diet, due to difficulties in consuming food and a tendency to conceal food while eating. He denied vomiting but was observed performing covert muscle contractions and stretching exercises. Pharmacological treatment included sertraline 50 mg/day, lorazepam 1.5 mg/day, and later risperidone 0.5 mg/day, all well tolerated. Cognitive distortions were identified around his body image, dietary components, and rigid thought patterns; which decreased as renutrition was completed. Psychoeducation was provided to the family, and a family-based intervention was implemented using the Maudsley Family-Based Therapy model, incorporating the family-oriented approach proposed by María Ganci (3). Outpatient follow-up was maintained. The patient showed strict adherence to the prescribed diet but also exhibited excessive commitment to physical exercise, which he performed daily. Case 2 Anamnesis and history of illness A 12-year-old boy, the older of two siblings. He had a history of anxiety disorder, with features of social anxiety, separation anxiety, and prominent obsessive-compulsive symptoms. During the year prior to the current evaluation, he had received inconsistent psychotherapy. The patient was referred to psychiatric evaluation by the Pediatrics Department due to digestive symptoms and stagnant growth in height and weight. At the time of the assessment, he was hospitalized in the Pediatrics Department for gastric distension. He reported that around 10–12 months earlier, he began to experience progressive, intrusive concerns and distress related to eating, which led him to restrict and select food more rigidly. He had established a caloric intake goal of 1,200–1,600 kcal per day. For this purpose, he skipped meals and increased physical activity (he wore a fitness tracker and woke up at 5:30 a.m. daily to exercise). He exhibited avoidance behaviors, anticipatory anxiety, ruminative thoughts, and mirror-checking behaviors, especially focused on his abdomen and legs, expressing a fear of “ getting fat or gaining weight ”. He expressed a desire to have a slightly larger physique, but only in terms of muscle mass. Additional symptoms included sadness, irritability at home, fatigue, and a tendency toward social withdrawal. Neither the patient nor his parents identified a specific triggering event. He maintained social functioning and positive peer relationships, although he was described as an inflexible child with a strong need for control. Family psychiatric history : No relevant history. Physical and psychopathological examination Weight : 31.2 kg, Height : 143 cm, BMI : 15.30 kg/m², Blood Pressure : 101/84 mmHg, Heart Rate : 71 bpm. He appeared serious, with appropriate affective resonance. His speech was minimizing and accommodating, yet fluent, detailed, and informative. There was intense rumination with intrusive, ego-dystonic thoughts about food, a tendency toward restriction and compensation through exercise, and guilt following episodes of perceived loss of control. He showed high self-demand, low frustration tolerance, and a strong need for control. Low mood with apathy, anhedonia, and irritability at home. He experienced psychological anticipatory anxiety before meals and post-meal anxiety when his intake did not meet self-imposed standards, though without somatic symptoms. He denied suicidal ideation or thoughts of death. He also presented fragmented sleep (waking up at 5:30 a.m. to exercise), reduced appetite and body dysmorphia, particularly focused on the abdomen. Partial insight. Diagnosis and recommended treatment The patient was diagnosed with Anorexia Nervosa with significantly low body weight, restricting pattern (ICD-11 6B80.00). Treatment was initiated with sertraline 50 mg/day, nutritional counseling, and psychotherapy. Outpatient follow-up was established, during which he showed progressive improvement in affective symptoms and gradual weight recovery, along with normalization of eating habits. However, he continued to have a low BMI one year later (last weight: 38.5 kg; BMI: 17.1 kg/m²; see Fig. 1 for evolution). Throughout follow-up, the patient showed a marked preference for weight gain exclusively in the form of muscle mass, especially in the abdominal region, with less interest in upper body development. Case 3 Anamnesis and history of illness A 14-year-old male, the older of two siblings, with a history of Attention Deficit Hyperactivity Disorder (ADHD, ICD-11 6A05.0) diagnosed at age 12. He was initially treated with psychostimulants, which were later discontinued due to headaches, dizziness, and significant weight loss. Other relevant personal history included separation anxiety symptoms and learning difficulties in reading and writing. The patient presented for evaluation due to hyporexia and a 19 kg weight loss over the past 10 months, having previously reached a maximum weight of 69 kg. This was initially triggered by a respiratory infection, which led to loss of appetite and early satiety. Around the same time, he began to prefer “ healthy ” foods and developed a strong interest in home cooking (particularly desserts), which he prepared but did not eat. He associated the intake of certain foods, such as meat, with abdominal bloating and increased bowel movements (up to 10 times per day), without achieving complete relief. He also showed increased daily physical activity and social withdrawal. He denied any dissatisfaction with his body or desire to achieve an idealized physical appearance. His pediatrician initiated treatment with appetite stimulants, but there was no improvement. Family psychiatric history : No relevant history. Physical and psychopathological examination Weight : 50 kg, Height : 170 cm, BMI : 17.30 kg/m², Blood Pressure : 100/84 mmHg, Heart Rate : 81 bpm Appropriate eye contact and normal response latency, with minimal and uninformative speech. Rumination around academic performance, low cognitive flexibility, poor frustration tolerance, and difficulty managing unexpected changes or uncertainty. He demonstrated perfectionism, high self-demands, and a fluctuating self-concept depending on whether his personal expectations were met. He exhibited low self-esteem and feelings of worthlessness in situations where he felt he had failed. Mild irritability at home was noted, without other mood symptoms. No thoughts of death. He showed decreased appetite and selective eating behavior, with partial insight into his condition. Diagnosis and recommended treatment He was diagnosed with Feeding or eating disorders, unspecified (ICD-11 6B8Z). Treatment included sertraline 50 mg/day, dietary counseling, and recommendations to reduce physical activity. Psychotherapy was not initiated due to patient refusal. The patient's progress was favorable. After 16 months, weight loss had stabilized (minimum weight: 46.6 kg; BMI: 16.3 kg/m²), and by the last follow-up, he had regained weight (54.7 kg; BMI: 18.7 kg/m²; see Fig. 1 for progress). He reported increased food intake in both quantity and frequency, along with improvements in academic performance and reduced social withdrawal. As clinical improvement was observed, physical activity was gradually reintroduced at the patient’s request with no further weight loss. At no point during follow-up were cognitive distortions regarding food intake or weight gain identified. Case 4 Anamnesis and history of illness A 9-year-old boy, the younger of two siblings, with no significant prior medical nor psychiatric history. He was referred for psychiatric evaluation after developing restrictive eating behaviors in response to sustained negative feedbackfrom peers about his weight over the past year. He began cutting meals in half, reporting gastrointestinal discomfort that prevented him from eating and simultaneously increased his physical activity to six days per week. He also spent time at home watching his mom cooking, possibly as a form of food control. He reported low mood, loss of interest and anhedonia, which he attributed to his mother's oncological illness. Due to worsening of his condition, he was brought to the Emergency Room, where bradycardia and hypoglycemia were noted. At that time, he weighed 30.8 kg (BMI 15.3 kg/m²). He was admitted to the Pediatrics Department and diagnosed with an Eating Disorder. Treatment was initiated with risperidone 0.5 mg/day. He was discharged with a weight of 32.3 kg (BMI 16.0 kg/m²). However, after discharge, his condition worsened again, with further weight loss, prompting outpatient psychiatric follow-up and a subsequent adjustment in pharmacological treatment. Family psychiatric history : Mother diagnosed with an anxiety disorder in the context of oncological illness; father and multiple paternal and maternal uncles have a history of enuresis; maternal grandfather has a history of adjustment disorder. Physical and psychopathological examination Weight : 33 kg, Height : 143.6 cm, BMI : 15.90 kg/m², Blood Pressure : 103/80 mmHg, Heart Rate : 76 bpm Partially cooperative, slow and uninformative speech. He exhibited bradypsychia and psychomotor slowing, with evident thinness. Ruminative thoughts about his weight and expressed distress about not being able to play soccer, along with cognitive distortions involving all types of food (he even avoided swallowing out of fear of gaining weight). Low mood, emotional lability, apathy, asthenia, and irritability. He reported anticipatory anxiety before meals, with somatic symptoms, feelings of guilt and low self-esteem. He expressed thoughts of death, though without suicidal ideation. Appetite was reduced and selective. Secondary enuresis. Partial insight. Diagnosis and recommended treatment The patient was diagnosed with Anorexia Nervosa with significantly low body weight, restricting pattern (ICD-11 6B80.00). Treatment was initiated with sertraline 50 mg/day and psychotherapy. Initial response showed improvement in affective symptoms and gradual weight recovery (see Fig. 1 for progression). During outpatient follow-up, a partial relapse occurred in 2022 at the same time his mother died and the onset of a new relationship with his father. As physical exercise had to be reduced again due to clinical worsening, his mood was further impacted. With increased frequency of outpatient visits, the patient showed improvement, with appropriate weight recovery. Although fear of weight regain persisted, it did not focus on specific body parts, yet it continued to affect his daily experience significantly. Case 5 Anamnesis and history of illness An 11-year-old boy, the youngest of three siblings. He presented to our outpatient clinic with dietary restrictions (primarily eliminating high-calorie foods), and had experienced weight loss over 4–5 months. His motivation was body dissatisfaction focused on his abdomen. He also engaged in compensatory behaviors, including increased physical exercise. Two months after symptom onset, he developed an inability to maintain adequate oral intake, even fluids, which led to psychomotor agitation. This was accompanied by low mood, social withdrawal, emotional lability, fatigue, loss of interest in activities, truancy, and discontinuation of extracurricular participation. Symptom onset coincided with a significant lifestyle change in his father, who after cardiovascular risk factors were identified, modified his diet to consume only " healthy " foods and began daily exercise. His father was later evaluated and diagnosed with an unspecified Eating Disorder and an Anxiety Disorder. After referral to Child Psychiatry, treatment was started with sertraline 50 mg/day and restricted physical activity, with slow progress. Two months later, his diet remained highly restricted, culminating in syncope due to hypotension. He was admitted to the Psychiatric Inpatient Unit, requiring enteral nutrition, initially exclusively, and later combined with oral feeding. The sertraline dose was increased to 100 mg/day, and clonazepam was initiated up to 0.5 mg/day. Post-discharge, he soon deteriorated again with marked food restriction, rumination, negative thoughts, feelings of worthlessness and guilt. Surprisingly, he did not engage in physical exercise during this period. All of this led to a new admission to the Psychiatric Inpatient Unit. Family Psychiatric History : The patient’s father, a paternal first cousin, and a paternal second cousin all have a history of Eating Disorders. Physical and psychopathological examination upon admission Weight : 29.3 kg, Height : 147.5 cm, BMI : 13.40 kg/m², Blood Pressure : 96/79 mmHg, Heart Rate : 67 bpm. The patient appeared malnourished and cachectic, with pale skin and mucous membranes. There was psychomotor and cognitive slowing, including bradypsychia and bradylalia with fragmented speech but goal-directed. He exhibited body dysmorphic symptoms with overrated ideas about food intake, alongside marked rumination about food and his current situation. Anticipatory anxiety around food intake. Low mood with apathy, anhedonia, anergy, social isolation, and negative thoughts about himself and his future. Appetite was severely decreased, leading to life-threatening weight loss. He reported passive thoughts of death, including thoughts of defenestration, but retained good control over these thoughts. Partial insight. Diagnosis and recommended treatment Diagnosed with Anorexia Nervosa with dangerously low body weight, restricting pattern (ICD-11 6B80.10), and a single episode depressive disorder, moderate, with psychotic symptoms (ICD-11 6A70.2). During the first admission, he remained hospitalized for 45 days, discharged weighing 34.2 kg (BMI 15.8 kg/m²) (see Fig. 1 for evolution). During the second admission, he again required enteral nutrition, gradually replacing it with 2,500 kcal/day oral intake. Sertraline was maintained at 100 mg/day, and clonazepam was titrated to 1.5 mg/day. Throughout hospitalization, the focus was on addressing overrated ideas through gradual exposure to oral feeding. Physical exercise was reintroduced gradually, with progressive acceptance of the physical changes experienced. DISCUSSION Eating disorders (EDs) are approximately ten times more common in women (Gorrell & Murray, 2019 ) (Ortuño Sánchez-Pedreño, 2022 ); however, several studies have reported a progressive increase in ED diagnoses among males over the past two decades, with rates rising from 10% to 25% in clinical populations (Richardson & Paslakis, 2021 ) (Franceschini & Fattore, 2021 ). Despite this trend, relatively few studies have specifically examined EDs in males. One of the most representative investigations was conducted in a non-clinical population of Australian adolescents, revealing that 12.8% of male participants met criteria for an ED, compared to 32.9% of females (Nagata et al., 2020 ). This is important also because pediatricians need to be informed of this change in illness trend, in order to detect possible cases quickly and refer them to a mental health professional for proper and prompt evaluation (Jiménez García et al., 2025 ). The scarcity of literature on this topic may contribute to underdiagnosis in males and a lack of gender-sensitive treatment approaches (Brown & Keel, 2023 ) (Richardson & Paslakis, 2021 ). This article presents a series of clinical cases from our center, highlighting key characteristics of EDs in male underage patients and outlining how these features may differ from the more commonly described presentations in females (see Table 1 for main differences). Findings indicate that the most prevalent Eating Disorder in males (both in childhood and adulthood) is Binge Eating Disorder (BED, ICD-11 6B82), followed by Bulimia Nervosa (ICD-11 6B81), and Anorexia Nervosa (ICD-11 6B80) (Gorrell & Murray, 2019 ) (Franceschini & Fattore, 2021 ). The female-to-male ratio is estimated at 10:1 for both Anorexia and Bulimia Nervosa, and approximately 2:1 for Binge Eating Disorder. Furthermore, Binge Eating Disorder displays more pronounced age-related differences, with higher prevalence rates in adults than in children, as well as significant cross-cultural variability (Brown & Keel, 2023 ). This pattern is not reflected in the case series presented here. The likely explanation for this discrepancy lies in selection bias: families may be more inclined to seek specialized care when clinical symptoms are severe, such as in cases of Anorexia Nervosa associated with life-threatening malnutrition. Additionally, the profile of our center and the broader lack of awareness surrounding EDs in males may further contribute to this diagnostic pattern. Risk Factors Several hypotheses have been proposed to explain why Eating Disorders are significantly more prevalent in women than in men. These include biological, social, and psychological factors: Hormonal factors : Eating behaviors appear to be influenced by reproductive hormones , particularly ovarian hormones rather than testosterone. These hormones may affect women's preferences for sweet, carbohydrate-rich, and high-fat foods and their fluctuation throughout the menstrual cycle may contribute to disordered eating patterns (Franceschini & Fattore, 2021 ) (Hay & Morris, 2017 ). In contrast, prenatal androgen exposure in males is thought to play a protective role against the development of Eating Disorders later in life (Brown & Keel, 2023 ). It is also important to note that prepubertal children lack significant androgenic influence (low testosterone levels at this stage may manifest as genital atrophy and the absence of morning erections), which may explain the appearance of Eating Disorders in underage males (Hay & Morris, 2017 ) (American Psychiatry Association, 2022 ). Additionally, several studies highlight the protective role of testosterone in reducing impulsive eating behaviors, such as binge eating (Franceschini & Fattore, 2021 ). Social factors : Among women, and particularly those with Eating Disorders, there is often a strong " desire for thinness ." In recent decades, this has expanded to include a desire for an athletic, lean or muscular physique (Gorrell & Murray, 2019 ) (Brown & Keel, 2023 ). In contrast, men with Eating Disorders often aim to reduce fat while increasing muscle mass, influenced by distinct social pressures and stereotypes (Gorrell & Murray, 2019 ). This situation may be intensified in males participating in sports that demand low body fat or in those with a history of childhood obesity (Franceschini & Fattore, 2021 ) (Nagata et al., 2020 ). This factor is clearly exemplified in our clinical series, particularly in Case 2. Moreover, traditional gender roles may hinder both patients’ self-recognition and clinicians’ identification of Eating Disorders in males, contributing to underdiagnosis them (Brown & Keel, 2023 ) (Franceschini & Fattore, 2021 ). Social minority status : Some studies report higher incidence peaks of Eating Disorders among white and latino adolescent males, whereas other ethnic groups exhibit a more stable incidence over time (Brown & Keel, 2023 ). Sexual orientation also plays a role: homosexuality has been identified as a risk factor in males, particularly in relation to purging behaviors and binge eating episodes (Gorrell & Murray, 2019 ) (Richardson & Paslakis, 2021 ) (Franceschini & Fattore, 2021 ) (Nagata et al., 2020 ). These risk factors were not observed in our clinical sample. Temperamental traits : Males with Eating Disorders tend to score lower than females on traits such as harm avoidance, reward dependence, cooperativeness, and perfectionism (Brown & Keel, 2023 ). Moreover, they often exhibit fewer difficulties with emotional dysregulation compared to their female counterparts. Still, common traits shared across genders include low cognitive flexibility, perfectionism, high self-imposed demands, a strong need for control, and difficulty adapting to change (Bruch, 2001 ). These features often intensify at the onset of the illness and may become more pronounced as the disorder progresses chronically. In all the cases presented in this series, these traits were evident both before the onset of symptoms and throughout the course of the illness. Symptoms The diagnostic criteria for Eating Disorders (EDs) do not differ between males and females according to international guidelines. The primary difficulty lies in the lack of recognition of EDs in males, a population traditionally considered to be at lower risk (Brown & Keel, 2023 ). With regard to purging behaviors , males with Eating Disorders are less likely to engage in self-induced vomiting or laxative use. Instead, they more frequently rely on excessive physical exercise, a behavior that both reinforces traditional masculine ideals and aligns with a preference for increased muscle mass (Gorrell & Murray, 2019 ) (Brown & Keel, 2023 ). A widely accepted sociocultural framework explaining the development of EDs in males is the Tripartite Influence Model, adapted by Tylka . This model posits that while cultural beauty ideals for women have historically emphasized thinness, male ideals are more focused on muscularity. Some authors describe this phenomenon as " inverted anorexia ", now formally recognized as “Muscle Dysmorphia ” in international diagnostic systems. In this condition, males perceive their muscles as inadequately developed despite objective evidence to the contrary. The model theorizes that sociocultural pressures drive internalization of the muscular ideal, leading to body dissatisfaction centered on body fat. This dissatisfaction often results in dietary changes aimed at increasing muscle mass (also known as drive for muscularity) together with drive for leanness (absence of body fat) such as elevated protein intake or even the use of anabolic substances (Lavender et al., 2017 ) (Gorrell & Murray, 2019 ) (Nagata et al., 2020 ) (Richardson & Paslakis, 2021 ) (Franceschini & Fattore, 2021 ) (Brown & Keel, 2023 ) (Upchurch, 2024 ) (Schmitt et al., 2025 ). Tipically, this symptomatology was related to sports like halterophilia, but recently other sports such as cyclism are being affected too (Mazaraki et al., 2024 ). Because these behaviors can easily be mistaken for healthy lifestyle choices, detection is often delayed. This delay exacerbates the individual’s suffering and contributes to the misconception that EDs are exclusively a female issue (Richardson & Paslakis, 2021 ). In this context, the clinical presentation of EDs in males frequently diverges from the traditional thinness-oriented model, shifting instead toward a muscularity-oriented phenotype (Gorrell & Murray, 2019 ). As observed in our case series—particularly Case 2 and Case 5—the psychological drive is often centered on achieving a lean yet muscular physique, a duality that complicates early clinical recognition (Lavender et al., 2017 ). This pursuit of muscularity is not merely aesthetic but is often a predictor of severe disordered eating behaviors, where the use of supplements and excessive training serves as a gateway to restrictive patterns (Nagata et al., 2020 ). In this context, compulsive physical exercise (defined as a persistent need to engage in intense physical activity despite negative consequences) emerges as a primary compensatory mechanism and a tool for emotion dysregulation, especially in athletic or highly self-demanding profiles (Mazaraki et al., 2024 ). A noticeable change in exercise patterns can precede any dietary changes and should be regarded as an early warning sign (Gorrell & Murray, 2019 ) (Brown & Keel, 2023 ). This pattern was evident in several cases within our clinical sample. Crucially, the extreme physiological strain and nutritional deficit inherent in these behaviors lead to profound endocrine disruption. In the absence of markers like amenorrhea, clinicians must look toward the suppression of the hypothalamic-pituitary-gonadal axis, which manifests as erectile dysfunction or the loss of morning erections—the biological male counterparts to female menstrual loss (Skolnick et al., 2016 ). Although this symptom may not be applicable to prepubertal children, it represents the biological counterpart to female amenorrhea and underscores the profound endocrine disruption common to both genders. This absence of a clear clinical indicator in boys contributes to underdiagnosis and diagnostic delays in this population (Gorrell & Murray, 2019 ). Other somatic symptoms , common to both sexes, include cardiac abnormalities (bradycardia), electrolyte imbalances and gastrointestinal disturbances (Nagata et al., 2020 ). In the absence of clear signs pointing to an Eating Disorder, these symptoms may be misattributed to unrelated conditions. Consequently, patients are often referred to other medical specialists, delaying appropriate psychiatric evaluation. Such delays increase psychological distress and heighten the risk of the disorder becoming chronic (Richardson & Paslakis, 2021 ). These features were present to varying degrees in the patients described in our case series. Finally, it is important to highlight potential differences in psychiatric comorbidities . Males with EDs more frequently present with anxiety disorders or psychotic features, whereas affective disorders are more common in females with EDs (Brown & Keel, 2023 ) (Franceschini & Fattore, 2021 ). All of these symptoms are related to concern about their body image (Schmitt et al., 2025 ). Finally, growth stagnation in both height and weight should be considered a critical warning sign of an underlying Eating Disorder in boys. This may be one of the few indirect markers of altered eating and/or exercise behaviors in this population. Diagnosis As discussed previously, there is a notable lack of diagnostic tools specifically designed for identifying eating disorders in males. Numerous studies have emphasized the need for assessment instruments that capture male-specific cognitive patterns, particularly those related to muscle mass development and muscularity-oriented body image concerns, rather than focusing solely on weight loss or the idealization of thinness (Gorrell & Murray, 2019 ) (Brown & Keel, 2023 ) (Richardson & Paslakis, 2021 ) (Nagata et al., 2020 ). The development and implementation of such tools would facilitate earlier and more accurate identification of eating disorders in male populations. Treatment Men with Eating Disorders remain underrepresented in treatment samples included in scientific research (Gorrell & Murray, 2019 ) (Brown & Keel, 2023 ). Several barriers hinder their access to care, barriers that are especially pronounced among adolescents and young adults compared to preadolescents. These include stigma, lack of awareness of available services, limited information on recognizing clinical risk and insufficient knowledge on how to seek help, both individually and within the family context (Gorrell & Murray, 2019 ) (Brown & Keel, 2023 ) (Richardson & Paslakis, 2021 ) (Franceschini & Fattore, 2021 ) (Nagata et al., 2020 ). Additionally, many existing treatment approaches have been developed based primarily on female populations and often fail to adequately address male-specific needs. These include concerns related to masculinity, muscularity, male physiological symptoms and stigma. As a result, treatment frameworks may not fully resonate with male patients or their lived experiences (Gorrell & Murray, 2019 ). To date, there are no empirically validated treatment protocols designed specifically for males with Eating Disorders. However, existing treatments are being adapted to better meet male patients' needs by incorporating discussions on stigma, muscularity-oriented body image concerns, and sex-specific physical and psychological presentations (Gorrell & Murray, 2019 ) (Ganci, 2021 ). More recently, a promising treatment paradigm, particularly for Anorexia Nervosa but applicable to other EDs, has emphasized the active involvement of the family in the therapeutic process. This family-based model empowers families to take an essential role in the patient's recovery process, moving beyond an individual-focused framework to a more systemic and supportive approach (Richardson & Paslakis, 2021 ) (Ganci, 2022 ). Encouragingly, studies examining treatment outcomes in men who do engage with services suggest that remission rates are high and treatment efficacy does not differ significantly by gender (Brown & Keel, 2023 ). This finding underscores the importance of facilitating earlier diagnosis and improving access to gender-sensitive care, rather than modifying the core therapeutic principles themselves. In conclusion, our case series underscores that while the core pathology of EDs remains consistent across genders, the clinical phenotype in males is often masked by sociocultural ideals of muscularity and a lack of gender-specific screening tools. Increasing clinical suspicion in male patients with growth stagnation or compulsive exercise is vital to preventing chronicity. Limitations While this case series provides valuable clinical insights into the presentation of Eating Disorders (EDs) in male children and adolescents, several limitations must be acknowledged: Sample Size and Selection Bias : As a series of five clinical cases, the findings cannot be generalized to the entire male population with EDs. Furthermore, the cases were recruited from a specialized Care Unit, which inherently introduces a selection bias toward more severe and medically unstable presentations (e.g., severe malnutrition or bradycardia). This may explain the predominance of Anorexia Nervosa in our sample, contrasting with broader epidemiological data that suggests Binge Eating Disorder is more prevalent in males. Retrospective Nature : The data were collected through clinical history and retrospective review of medical records. This may lead to "recall bias" or the omission of certain longitudinal variables that were not systematically recorded at the time of the first consultation. Diagnostic Tools : The lack of standardized, male-specific psychometric instruments during the initial assessment may have limited our ability to quantify specific symptoms like muscle dysmorphia or exercise-related body dissatisfaction with the same precision as weight-related concerns. Follow-up Period : Although the evolution of the patients is described, the follow-up period varies between cases. A longer longitudinal monitoring would be necessary to assess long-term remission rates and the risk of relapse specifically in this male cohort. Single-Center Study : The findings reflect the clinical practice and demographic characteristics of a specific geographic area and a single healthcare facility, which may not represent the socio-cultural diversity seen in other regions. CONCLUSIONS Eating Disorders demonstrate a female-to-male ratio of approximately 10:1, contributing to the underdiagnosis of these conditions in males. However, recent evidence suggests a progressive increase in incidence among males, at least within clinical populations. Therefore, pediatricians need to be trained and informed about early detection and treatment. While Binge Eating Disorder (ICD-11 6B82) is epidemiologically the most prevalent ED in males, followed by Bulimia Nervosa (ICD-11 6B81) and Anorexia Nervosa (ICD-11 6B80), clinical severity often leads to a higher representation of restrictive patterns in specialized units. Unlike females, males with EDs are frequently motivated by a dual desire: reducing body fat while simultaneously increasing muscle mass. Diagnostic tools mes, therefore, be tailored to assess these specific muscularity-oriented concerns, rather than focusing exclusivelyon weight loss or thinness ideals. Compulsive physical exercise and/or a suddenchanges in activity patterns often represent some of the earliest warning signs of an Eating Disorder in males, often preceding overt dietary restriction. Traditional compensatory behaviors, such as such as self-induced vomiting or laxative misuse, appear to be lees frequent in this group. The absence of gender-specific physiological markers (such as amenorrhea) and the lack of observable androgenic alterations in prepubertal boys complicate early diagnosis. In this context, stagnation in height and weight should be regarded as a critical clinical "red flag" warranting immediate psychiatric evaluation. . It is essential to develop gender-sensitive diagnostic instruments and validated treatment protocols, ultimately improving clinical recognition and long-term outcomes for this traditionally underserved population.. Declarations COMPETING INTEREST The authors declare no conflicts of interest. FUNDING No funding was received for this study. ARTIFICIAL INTELLIGENCE (AI) USE No AI software has been used to prepare the manuscript. AUTHOR CONTRIBUTION All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Ruth Arias-Hidalgo, Covadonga Canga-Espina and Azucena Díez-Suárez. The first draft of the manuscript was written by Ruth Arias-Hidalgo and Covadonga Canga-Espina and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. AVAILABILITY OF DATA AND MATERIALS The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References American Psychiatry Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) . Brown, T. A., & Keel, P. K. (2023). Eating Disorders in Boys and Men. Annual Review of Clinical Psychology , 19 (1), 177–205. https://doi.org/10.1146/annurev-clinpsy-080921-074125 Bruch, H. (2001). La jaula dorada: el enigma de la anorexia nerviosa . Franceschini, A., & Fattore, L. (2021). Gender-specific approach in psychiatric diseases: Because sex matters. European Journal of Pharmacology , 896 , 173895. https://doi.org/10.1016/j.ejphar.2021.173895 Ganci, M. (2021). Hold My Hand: Parent Guide for the Treatment of Child and Adolescent Anorexia Nervosa and Atypical Anorexia Nervosa (L. Publishing (ed.)). Ganci, M. (2022). Sobrevivir al FBT:: manual de habilidades para padres que realizan un tratamiento basado en la familia (FBT) para la anorexia nerviosa en niñas y adolescentes . Gorrell, S., & Murray, S. B. (2019). Eating Disorders in Males. Child and Adolescent Psychiatric Clinics of North America , 28 (4), 641–651. https://doi.org/10.1016/j.chc.2019.05.012 Hay, P., & Morris, J. (2017). Trastornos alimentarios (Irarrazaval M, Martin A. eds Prieto-Tagle F, ed.). Manual de Salud Mental Infantil y Adolescente de La IACAPAP , 9 (1), 26. Jiménez García, R., Canga-Espina, C., Múñoz Domenjó, A., Ochando Perales, G., & Díez-Suárez, A. (2025). Trastornos de la conducta alimentaria: intervención del pediatra en la prevención, detección precoz, evaluación y tratamiento interdisciplinar. Anales de Pediatría , 503907. https://doi.org/10.1016/j.anpedi.2025.503907 Lavender, J. M., Brown, T. A., & Murray, S. B. (2017). Men, Muscles, and Eating Disorders: an Overview of Traditional and Muscularity-Oriented Disordered Eating. Current Psychiatry Reports , 19 (6), 32. https://doi.org/10.1007/s11920-017-0787-5 Mazaraki, J., Bussey, K., Cunningham, M., Jewell, T., & Trompeter, N. (2024). Muscularity-oriented disordered eating: investigating body image concerns and the moderating role of emotion dysregulation in cyclists. Journal of Eating Disorders , 12 (1), 189. https://doi.org/10.1186/s40337-024-01109-6 Nagata, J. M., Ganson, K. T., & Murray, S. B. (2020). Eating disorders in adolescent boys and young men: an update. Current Opinion in Pediatrics , 32 (4), 476–481. https://doi.org/10.1097/MOP.0000000000000911 Ortuño Sánchez-Pedreño, F. (2022). Lecciones de psiquiatría (Editorial Médica Panamericana (ed.); Second). Richardson, C., & Paslakis, G. (2021). Men’s experiences of eating disorder treatment: A qualitative systematic review of men-only studies. Journal of Psychiatric and Mental Health Nursing , 28 (2), 237–250. https://doi.org/10.1111/jpm.12670 Schmitt, A., Frenser, M., & Fischer, T. (2025). Tendencies of eating disordered behaviours in male content creators: a social media analysis. Journal of Eating Disorders , 13 (1), 201. https://doi.org/10.1186/s40337-025-01395-8 Skolnick, A., Schulman, R. C., Galindo, R. J., & Mechanick, J. I. (2016). The Endocrinopathies of Male Anorexia Nervosa: Case Series. AACE Clinical Case Reports , 2 (4), e351–e357. https://doi.org/10.4158/EP15945.CR Upchurch, A. (2024). Muscularity oriented disordered eating and exercise in adult male exercisers: A quantitative analysis [Adler University]. https://www.proquest.com/dissertations-theses/muscularity-oriented-disordered-eating-exercise/docview/3258801734/se-2 Additional Declarations No competing interests reported. Supplementary Files ANNEXE.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9428669","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628397683,"identity":"55ad019f-81d1-48f5-bfd8-f124dd36cd7e","order_by":0,"name":"Ruth Arias-Hidalgo","email":"","orcid":"","institution":"Hospital Universitario Puerta de Hierro Majadahonda","correspondingAuthor":false,"prefix":"","firstName":"Ruth","middleName":"","lastName":"Arias-Hidalgo","suffix":""},{"id":628397684,"identity":"6d1e69d7-3887-4398-b198-a7c4e8c7e039","order_by":1,"name":"Covadonga Canga-Espina","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAs0lEQVRIiWNgGAWjYPACG9K1pJGu5TAJavnbDz97+KXmfOJ29jMGDB/+EKFF4kyaubHMsduJO3tyDBhnthGhxUCCwUxagu124oYDaQnMvA1EaWH/Ji3x71zihvPPEpj/EOMwAwkeM8mPbQcSN9xIPsDMwEaEFokzOWXSjH3JxhtuPD5wsJcYv/C3H98m+eObneyG84mND34Q4zAQYOaBMg4QqYGBgfEH0UpHwSgYBaNgRAIAVL44I/3Ji1IAAAAASUVORK5CYII=","orcid":"","institution":"Clínica Universidad de Navarra","correspondingAuthor":true,"prefix":"","firstName":"Covadonga","middleName":"","lastName":"Canga-Espina","suffix":""},{"id":628397685,"identity":"7c12c8bc-508d-4f96-94e1-11df83a53048","order_by":2,"name":"Azucena Díez-Suárez","email":"","orcid":"","institution":"Clínica Universidad de Navarra","correspondingAuthor":false,"prefix":"","firstName":"Azucena","middleName":"","lastName":"Díez-Suárez","suffix":""}],"badges":[],"createdAt":"2026-04-15 15:18:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9428669/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9428669/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108344767,"identity":"2a2b0cb2-d83e-4d6f-9716-8eaf79e97300","added_by":"auto","created_at":"2026-05-03 07:10:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":291140,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9428669/v1/ca90533f-f9d0-4a23-a85b-f95404dc52b6.pdf"},{"id":107914709,"identity":"dd3c9f9a-b04b-42d7-80df-eeb16778278d","added_by":"auto","created_at":"2026-04-27 14:00:26","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1150768,"visible":true,"origin":"","legend":"","description":"","filename":"ANNEXE.docx","url":"https://assets-eu.researchsquare.com/files/rs-9428669/v1/7ff882318de7015ccf664e1b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond the Drive for Thinness: Clinical Characteristics and Diagnostic Red Flags in Male Pediatric Eating Disorders: A Case Series","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eEating disorders (EDs) are psychiatric illnesses associated with significant morbidity and mortality, as they are the leading cause of malnutrition in Western countries and rank among the mental illnesses with the highest rates of direct mortality. EDs are also among the psychiatric disorders most strongly associated with gender, with a lower prevalence observed in men; the female-to-male ratios are approximately 10:1 for Anorexia Nervosa (AN, ICD-11 6B80) and Bulimia Nervosa (BN, ICD-11 6B81), and 2:1 for Binge Eating Disorder (BED, ICD-11 6B82). This gender disparity has lead to a scarcity of literature on EDs in males, resulting in a limited understanding of the disorder and a lack of specific clinical guidance for this specific population (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo address this gap,we present a series of five clinical cases involving male patients under 18 years of age who attended our Child and Adolescent Psychiatry Outpatient Unit between 2022 and 2023.\u003c/p\u003e \u003cp\u003eThe study protocol was approved by the local Ethics Committee (project 2025.283). All data were de-identified to ensure patient confidentiality in accordance with the Declaration of Helsinki and Spanish Organic Law 3/2018, of December 5, on the Protection of Personal Data and the guarantee of digital rights, and its latest update in Law 11/2023, published on May 9, 2023 (previously replacing Directive 95/46/EC of the European Parliament and of the Council, of October 24, 1995, on the protection of natural persons with regard to the processing of personal data and on the free movement of such data).\u003c/p\u003e \u003cp\u003eAll patients who come to our clinic agree that their information may be used for medical or research purposes, as long as they cannot be identified through the same.\u003c/p\u003e"},{"header":"CASE SERIES","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCase 1\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eAnamnesis and history of illness\u003c/h2\u003e \u003cp\u003eA 15-year-old male, only child, with no significant past medical history.\u003c/p\u003e \u003cp\u003eTwo years prior, he began to express concerns about his physical appearance and a desire to lose weight following negative peers\u0026rsquo; comments about his body. This led to restrictive eating behaviors, increased physical activity, and progressive weight loss. Subsequently, he experienced loss of control over eating, followed by self-induced vomiting, initially suggested by a classmate. At onset, his height was 170 cm and his weight was 74 kg (Body Mass Indexz \u0026ndash;BMI \u0026ndash;: 25.6 kg/m\u0026sup2;); through purging, he reduced his weight to 62 kg. During summer, his restrictive eating intensified, leading to severe anxiety around food exposure, as well as symptoms of sadness, lack of motivation, fatigue, feelings of worthlessness, low self-esteem, and guilt; associated with a three-month period of school absenteeism. Despite receiving care from a psychologist (not specialized in clinical psychology) and a nutritionist, his progress was minimal. Three months later, he presented at the Emergency Room with severe malnutrition, having lost 38% of his initial body weight. At that time, he denied ongoing purging behaviors but exhibited intense body dysmorphic symptoms, multiple cognitive distortions, and occasional passive thoughts of death.\u003c/p\u003e \u003cp\u003eHis mother acknowledged having a restrictive eating pattern herself, linked to her perimenopausal stage, and admitted to a certain preoccupation with body image.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFamily Psychiatric History\u003c/span\u003e: Father with anxiety symptoms, and mother with a history of altered eating behaviors, anxiety, and occasional dissociative episodes; however, neither had received specific treatment.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003ePhysical and psychopathological examination (dup: abstract ?)\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eWeight\u003c/em\u003e: 46 kg, \u003cem\u003eHeight\u003c/em\u003e: 178 cm, \u003cem\u003eBMI\u003c/em\u003e: 14.50 kg/m\u0026sup2;, \u003cem\u003eHeart Rate\u003c/em\u003e: 33 bpm, \u003cem\u003eBlood Pressure\u003c/em\u003e: 92/60 mmHg.\u003c/p\u003e \u003cp\u003eThe patient appeared severely malnourished, with psychomotor retardation, dry mucous membranes, hypotonia (barely able to hold up his head), and hypothermia. His facial expression was hypomimic, with avoidant eye contact, delayed response latency, and decreased attention span. Speech was minimizing and excessively accommodating, with apparent indifference, and marked feelings of inadequacy, worthlessness, and incapacity. His self-esteem was low, with persistent preoccupation around body image. He exhibited multiple cognitive distortions and overvalued ideas related to weight and nutrition, including a desire for increased muscle mass in the chest and arms, and a flat abdomen.\u003c/p\u003e \u003cp\u003eLow mood with apathy, anhedonia, asthenia, emotional lability, and occasional irritability. He reported passive thoughts of death, without active suicidal ideation. Partial insight.\u003c/p\u003e\n\u003ch3\u003eDiagnosis and recommended treatment (dup: abstract ?)\u003c/h3\u003e\n\u003cp\u003eThe patient was diagnosed with Anorexia Nervosa with significantly low body weight, restricting pattern (ICD-11 6B80.00) and a moderate depressive episode without psychotic symptoms (ICD-11 6A70.1), along with bradycardia.\u003c/p\u003e \u003cp\u003eHe was urgently admitted to the inpatient unit, where he remained for 70 days, followed by a 10-day admission to the Day Hospital. Upon discharge, his weight was 61 kg (BMI: 18.9), showing improvement in his overall condition and resolution of bradycardia (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for progress). He required electrocardiographic monitoring and nighttime enteral nutrition in addition to an oral diet, due to difficulties in consuming food and a tendency to conceal food while eating. He denied vomiting but was observed performing covert muscle contractions and stretching exercises. Pharmacological treatment included sertraline 50 mg/day, lorazepam 1.5 mg/day, and later risperidone 0.5 mg/day, all well tolerated. Cognitive distortions were identified around his body image, dietary components, and rigid thought patterns; which decreased as renutrition was completed. Psychoeducation was provided to the family, and a family-based intervention was implemented using the Maudsley Family-Based Therapy model, incorporating the family-oriented approach proposed by Mar\u0026iacute;a Ganci (3). Outpatient follow-up was maintained. The patient showed strict adherence to the prescribed diet but also exhibited excessive commitment to physical exercise, which he performed daily.\u003c/p\u003e\n\u003ch3\u003eCase 2\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnamnesis and history of illness\u003c/h2\u003e \u003cp\u003eA 12-year-old boy, the older of two siblings. He had a history of anxiety disorder, with features of social anxiety, separation anxiety, and prominent obsessive-compulsive symptoms. During the year prior to the current evaluation, he had received inconsistent psychotherapy.\u003c/p\u003e \u003cp\u003eThe patient was referred to psychiatric evaluation by the Pediatrics Department due to digestive symptoms and stagnant growth in height and weight. At the time of the assessment, he was hospitalized in the Pediatrics Department for gastric distension. He reported that around 10\u0026ndash;12 months earlier, he began to experience progressive, intrusive concerns and distress related to eating, which led him to restrict and select food more rigidly. He had established a caloric intake goal of 1,200\u0026ndash;1,600 kcal per day. For this purpose, he skipped meals and increased physical activity (he wore a fitness tracker and woke up at 5:30 a.m. daily to exercise). He exhibited avoidance behaviors, anticipatory anxiety, ruminative thoughts, and mirror-checking behaviors, especially focused on his abdomen and legs, expressing a fear of \u0026ldquo;\u003cem\u003egetting fat or gaining weight\u003c/em\u003e\u0026rdquo;. He expressed a desire to have a slightly larger physique, but only in terms of muscle mass. Additional symptoms included sadness, irritability at home, fatigue, and a tendency toward social withdrawal. Neither the patient nor his parents identified a specific triggering event. He maintained social functioning and positive peer relationships, although he was described as an inflexible child with a strong need for control.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFamily psychiatric history\u003c/span\u003e: No relevant history.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePhysical and psychopathological examination\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eWeight\u003c/em\u003e: 31.2 kg, \u003cem\u003eHeight\u003c/em\u003e: 143 cm, \u003cem\u003eBMI\u003c/em\u003e: 15.30 kg/m\u0026sup2;, \u003cem\u003eBlood Pressure\u003c/em\u003e: 101/84 mmHg, \u003cem\u003eHeart Rate\u003c/em\u003e: 71 bpm.\u003c/p\u003e \u003cp\u003eHe appeared serious, with appropriate affective resonance. His speech was minimizing and accommodating, yet fluent, detailed, and informative. There was intense rumination with intrusive, ego-dystonic thoughts about food, a tendency toward restriction and compensation through exercise, and guilt following episodes of perceived loss of control. He showed high self-demand, low frustration tolerance, and a strong need for control. Low mood with apathy, anhedonia, and irritability at home. He experienced psychological anticipatory anxiety before meals and post-meal anxiety when his intake did not meet self-imposed standards, though without somatic symptoms. He denied suicidal ideation or thoughts of death. He also presented fragmented sleep (waking up at 5:30 a.m. to exercise), reduced appetite and body dysmorphia, particularly focused on the abdomen. Partial insight.\u003c/p\u003e\n\u003ch3\u003eDiagnosis and recommended treatment\u003c/h3\u003e\n\u003cp\u003eThe patient was diagnosed with Anorexia Nervosa with significantly low body weight, restricting pattern (ICD-11 6B80.00).\u003c/p\u003e \u003cp\u003eTreatment was initiated with sertraline 50 mg/day, nutritional counseling, and psychotherapy. Outpatient follow-up was established, during which he showed progressive improvement in affective symptoms and gradual weight recovery, along with normalization of eating habits. However, he continued to have a low BMI one year later (last weight: 38.5 kg; BMI: 17.1 kg/m\u0026sup2;; see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for evolution). Throughout follow-up, the patient showed a marked preference for weight gain exclusively in the form of muscle mass, especially in the abdominal region, with less interest in upper body development.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCase 3\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eAnamnesis and history of illness\u003c/h2\u003e \u003cp\u003eA 14-year-old male, the older of two siblings, with a history of Attention Deficit Hyperactivity Disorder (ADHD, ICD-11 6A05.0) diagnosed at age 12. He was initially treated with psychostimulants, which were later discontinued due to headaches, dizziness, and significant weight loss. Other relevant personal history included separation anxiety symptoms and learning difficulties in reading and writing.\u003c/p\u003e \u003cp\u003eThe patient presented for evaluation due to hyporexia and a 19 kg weight loss over the past 10 months, having previously reached a maximum weight of 69 kg. This was initially triggered by a respiratory infection, which led to loss of appetite and early satiety. Around the same time, he began to prefer \u0026ldquo;\u003cem\u003ehealthy\u003c/em\u003e\u0026rdquo; foods and developed a strong interest in home cooking (particularly desserts), which he prepared but did not eat. He associated the intake of certain foods, such as meat, with abdominal bloating and increased bowel movements (up to 10 times per day), without achieving complete relief. He also showed increased daily physical activity and social withdrawal. He denied any dissatisfaction with his body or desire to achieve an idealized physical appearance. His pediatrician initiated treatment with appetite stimulants, but there was no improvement.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFamily psychiatric history\u003c/span\u003e: No relevant history.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePhysical and psychopathological examination\u003c/h2\u003e \u003cp\u003e \u003cem\u003eWeight\u003c/em\u003e: 50 kg, \u003cem\u003eHeight\u003c/em\u003e: 170 cm, \u003cem\u003eBMI\u003c/em\u003e: 17.30 kg/m\u0026sup2;, \u003cem\u003eBlood Pressure\u003c/em\u003e: 100/84 mmHg, \u003cem\u003eHeart Rate\u003c/em\u003e: 81 bpm\u003c/p\u003e \u003cp\u003eAppropriate eye contact and normal response latency, with minimal and uninformative speech. Rumination around academic performance, low cognitive flexibility, poor frustration tolerance, and difficulty managing unexpected changes or uncertainty. He demonstrated perfectionism, high self-demands, and a fluctuating self-concept depending on whether his personal expectations were met. He exhibited low self-esteem and feelings of worthlessness in situations where he felt he had failed. Mild irritability at home was noted, without other mood symptoms. No thoughts of death. He showed decreased appetite and selective eating behavior, with partial insight into his condition.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDiagnosis and recommended treatment\u003c/h2\u003e \u003cp\u003eHe was diagnosed with Feeding or eating disorders, unspecified (ICD-11 6B8Z).\u003c/p\u003e \u003cp\u003eTreatment included sertraline 50 mg/day, dietary counseling, and recommendations to reduce physical activity. Psychotherapy was not initiated due to patient refusal. The patient's progress was favorable. After 16 months, weight loss had stabilized (minimum weight: 46.6 kg; BMI: 16.3 kg/m\u0026sup2;), and by the last follow-up, he had regained weight (54.7 kg; BMI: 18.7 kg/m\u0026sup2;; see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for progress). He reported increased food intake in both quantity and frequency, along with improvements in academic performance and reduced social withdrawal. As clinical improvement was observed, physical activity was gradually reintroduced at the patient\u0026rsquo;s request with no further weight loss. At no point during follow-up were cognitive distortions regarding food intake or weight gain identified.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCase 4\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eAnamnesis and history of illness\u003c/h2\u003e \u003cp\u003eA 9-year-old boy, the younger of two siblings, with no significant prior medical nor psychiatric history.\u003c/p\u003e \u003cp\u003eHe was referred for psychiatric evaluation after developing restrictive eating behaviors in response to sustained negative feedbackfrom peers about his weight over the past year. He began cutting meals in half, reporting gastrointestinal discomfort that prevented him from eating and simultaneously increased his physical activity to six days per week. He also spent time at home watching his mom cooking, possibly as a form of food control. He reported low mood, loss of interest and anhedonia, which he attributed to his mother's oncological illness. Due to worsening of his condition, he was brought to the Emergency Room, where bradycardia and hypoglycemia were noted. At that time, he weighed 30.8 kg (BMI 15.3 kg/m\u0026sup2;). He was admitted to the Pediatrics Department and diagnosed with an Eating Disorder. Treatment was initiated with risperidone 0.5 mg/day. He was discharged with a weight of 32.3 kg (BMI 16.0 kg/m\u0026sup2;). However, after discharge, his condition worsened again, with further weight loss, prompting outpatient psychiatric follow-up and a subsequent adjustment in pharmacological treatment.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFamily psychiatric history\u003c/span\u003e: Mother diagnosed with an anxiety disorder in the context of oncological illness; father and multiple paternal and maternal uncles have a history of enuresis; maternal grandfather has a history of adjustment disorder.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePhysical and psychopathological examination\u003c/h2\u003e \u003cp\u003e \u003cem\u003eWeight\u003c/em\u003e: 33 kg, \u003cem\u003eHeight\u003c/em\u003e: 143.6 cm, \u003cem\u003eBMI\u003c/em\u003e: 15.90 kg/m\u0026sup2;, \u003cem\u003eBlood Pressure\u003c/em\u003e: 103/80 mmHg, \u003cem\u003eHeart Rate\u003c/em\u003e: 76 bpm\u003c/p\u003e \u003cp\u003ePartially cooperative, slow and uninformative speech. He exhibited bradypsychia and psychomotor slowing, with evident thinness. Ruminative thoughts about his weight and expressed distress about not being able to play soccer, along with cognitive distortions involving all types of food (he even avoided swallowing out of fear of gaining weight). Low mood, emotional lability, apathy, asthenia, and irritability. He reported anticipatory anxiety before meals, with somatic symptoms, feelings of guilt and low self-esteem. He expressed thoughts of death, though without suicidal ideation. Appetite was reduced and selective. Secondary enuresis. Partial insight.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eDiagnosis and recommended treatment\u003c/h2\u003e \u003cp\u003eThe patient was diagnosed with Anorexia Nervosa with significantly low body weight, restricting pattern (ICD-11 6B80.00).\u003c/p\u003e \u003cp\u003eTreatment was initiated with sertraline 50 mg/day and psychotherapy. Initial response showed improvement in affective symptoms and gradual weight recovery (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for progression). During outpatient follow-up, a partial relapse occurred in 2022 at the same time his mother died and the onset of a new relationship with his father. As physical exercise had to be reduced again due to clinical worsening, his mood was further impacted. With increased frequency of outpatient visits, the patient showed improvement, with appropriate weight recovery. Although fear of weight regain persisted, it did not focus on specific body parts, yet it continued to affect his daily experience significantly.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCase 5\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eAnamnesis and history of illness\u003c/h2\u003e \u003cp\u003eAn 11-year-old boy, the youngest of three siblings.\u003c/p\u003e \u003cp\u003eHe presented to our outpatient clinic with dietary restrictions (primarily eliminating high-calorie foods), and had experienced weight loss over 4\u0026ndash;5 months. His motivation was body dissatisfaction focused on his abdomen. He also engaged in compensatory behaviors, including increased physical exercise. Two months after symptom onset, he developed an inability to maintain adequate oral intake, even fluids, which led to psychomotor agitation. This was accompanied by low mood, social withdrawal, emotional lability, fatigue, loss of interest in activities, truancy, and discontinuation of extracurricular participation. Symptom onset coincided with a significant lifestyle change in his father, who after cardiovascular risk factors were identified, modified his diet to consume only \"\u003cem\u003ehealthy\u003c/em\u003e\" foods and began daily exercise. His father was later evaluated and diagnosed with an unspecified Eating Disorder and an Anxiety Disorder.\u003c/p\u003e \u003cp\u003eAfter referral to Child Psychiatry, treatment was started with sertraline 50 mg/day and restricted physical activity, with slow progress. Two months later, his diet remained highly restricted, culminating in syncope due to hypotension. He was admitted to the Psychiatric Inpatient Unit, requiring enteral nutrition, initially exclusively, and later combined with oral feeding. The sertraline dose was increased to 100 mg/day, and clonazepam was initiated up to 0.5 mg/day. Post-discharge, he soon deteriorated again with marked food restriction, rumination, negative thoughts, feelings of worthlessness and guilt. Surprisingly, he did not engage in physical exercise during this period. All of this led to a new admission to the Psychiatric Inpatient Unit.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFamily Psychiatric History\u003c/span\u003e: The patient\u0026rsquo;s father, a paternal first cousin, and a paternal second cousin all have a history of Eating Disorders.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePhysical and psychopathological examination upon admission\u003c/h2\u003e \u003cp\u003e \u003cem\u003eWeight\u003c/em\u003e: 29.3 kg, \u003cem\u003eHeight\u003c/em\u003e: 147.5 cm, \u003cem\u003eBMI\u003c/em\u003e: 13.40 kg/m\u0026sup2;, \u003cem\u003eBlood Pressure\u003c/em\u003e: 96/79 mmHg, \u003cem\u003eHeart Rate\u003c/em\u003e: 67 bpm.\u003c/p\u003e \u003cp\u003eThe patient appeared malnourished and cachectic, with pale skin and mucous membranes. There was psychomotor and cognitive slowing, including bradypsychia and bradylalia with fragmented speech but goal-directed. He exhibited body dysmorphic symptoms with overrated ideas about food intake, alongside marked rumination about food and his current situation. Anticipatory anxiety around food intake. Low mood with apathy, anhedonia, anergy, social isolation, and negative thoughts about himself and his future. Appetite was severely decreased, leading to life-threatening weight loss. He reported passive thoughts of death, including thoughts of defenestration, but retained good control over these thoughts. Partial insight.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eDiagnosis and recommended treatment\u003c/h2\u003e \u003cp\u003eDiagnosed with Anorexia Nervosa with dangerously low body weight, restricting pattern (ICD-11 6B80.10), and a single episode depressive disorder, moderate, with psychotic symptoms (ICD-11 6A70.2).\u003c/p\u003e \u003cp\u003eDuring the first admission, he remained hospitalized for 45 days, discharged weighing 34.2 kg (BMI 15.8 kg/m\u0026sup2;) (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for evolution). During the second admission, he again required enteral nutrition, gradually replacing it with 2,500 kcal/day oral intake. Sertraline was maintained at 100 mg/day, and clonazepam was titrated to 1.5 mg/day. Throughout hospitalization, the focus was on addressing overrated ideas through gradual exposure to oral feeding. Physical exercise was reintroduced gradually, with progressive acceptance of the physical changes experienced.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eEating disorders (EDs) are approximately ten times more common in women (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Ortu\u0026ntilde;o S\u0026aacute;nchez-Pedre\u0026ntilde;o, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e); however, several studies have reported a progressive increase in ED diagnoses among males over the past two decades, with rates rising from 10% to 25% in clinical populations (Richardson \u0026amp; Paslakis, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Franceschini \u0026amp; Fattore, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Despite this trend, relatively few studies have specifically examined EDs in males. One of the most representative investigations was conducted in a non-clinical population of Australian adolescents, revealing that 12.8% of male participants met criteria for an ED, compared to 32.9% of females (Nagata et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This is important also because pediatricians need to be informed of this change in illness trend, in order to detect possible cases quickly and refer them to a mental health professional for proper and prompt evaluation (Jim\u0026eacute;nez Garc\u0026iacute;a et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The scarcity of literature on this topic may contribute to underdiagnosis in males and a lack of gender-sensitive treatment approaches (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) (Richardson \u0026amp; Paslakis, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis article presents a series of clinical cases from our center, highlighting key characteristics of EDs in male underage patients and outlining how these features may differ from the more commonly described presentations in females (see \u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e for main differences).\u003c/p\u003e \u003cp\u003eFindings indicate that the most prevalent Eating Disorder in males (both in childhood and adulthood) is Binge Eating Disorder (BED, ICD-11 6B82), followed by Bulimia Nervosa (ICD-11 6B81), and Anorexia Nervosa (ICD-11 6B80) (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Franceschini \u0026amp; Fattore, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The female-to-male ratio is estimated at 10:1 for both Anorexia and Bulimia Nervosa, and approximately 2:1 for Binge Eating Disorder. Furthermore, Binge Eating Disorder displays more pronounced age-related differences, with higher prevalence rates in adults than in children, as well as significant cross-cultural variability (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This pattern is not reflected in the case series presented here. The likely explanation for this discrepancy lies in selection bias: families may be more inclined to seek specialized care when clinical symptoms are severe, such as in cases of Anorexia Nervosa associated with life-threatening malnutrition. Additionally, the profile of our center and the broader lack of awareness surrounding EDs in males may further contribute to this diagnostic pattern.\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eRisk Factors\u003c/h2\u003e \u003cp\u003eSeveral hypotheses have been proposed to explain why Eating Disorders are significantly more prevalent in women than in men. These include biological, social, and psychological factors:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eHormonal factors\u003c/em\u003e: Eating behaviors appear to be influenced by \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ereproductive hormones\u003c/span\u003e, particularly ovarian hormones rather than testosterone. These hormones may affect women's preferences for sweet, carbohydrate-rich, and high-fat foods and their fluctuation throughout the menstrual cycle may contribute to disordered eating patterns (Franceschini \u0026amp; Fattore, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Hay \u0026amp; Morris, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In contrast, prenatal androgen exposure in males is thought to play a protective role against the development of Eating Disorders later in life (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It is also important to note that prepubertal children lack significant \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eandrogenic influence\u003c/span\u003e (low testosterone levels at this stage may manifest as genital atrophy and the absence of morning erections), which may explain the appearance of Eating Disorders in underage males (Hay \u0026amp; Morris, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) (American Psychiatry Association, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Additionally, several studies highlight the protective role of testosterone in reducing impulsive eating behaviors, such as binge eating (Franceschini \u0026amp; Fattore, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eSocial factors\u003c/em\u003e: Among women, and particularly those with Eating Disorders, there is often a strong \"\u003cem\u003edesire for thinness\u003c/em\u003e.\" In recent decades, this has expanded to include a desire for an athletic, lean or muscular physique (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In contrast, men with Eating Disorders often aim to reduce fat while increasing muscle mass, influenced by distinct social pressures and stereotypes (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). This situation may be intensified in males participating in sports that demand low body fat or in those with a history of childhood obesity (Franceschini \u0026amp; Fattore, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Nagata et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This factor is clearly exemplified in our clinical series, particularly in Case 2. Moreover, traditional gender roles may hinder both patients\u0026rsquo; self-recognition and clinicians\u0026rsquo; identification of Eating Disorders in males, contributing to underdiagnosis them (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) (Franceschini \u0026amp; Fattore, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eSocial minority status\u003c/em\u003e: Some studies report higher incidence peaks of Eating Disorders among white and latino adolescent males, whereas other ethnic groups exhibit a more stable incidence over time (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Sexual orientation also plays a role: homosexuality has been identified as a risk factor in males, particularly in relation to purging behaviors and binge eating episodes (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Richardson \u0026amp; Paslakis, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Franceschini \u0026amp; Fattore, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Nagata et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These risk factors were not observed in our clinical sample.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eTemperamental traits\u003c/em\u003e: Males with Eating Disorders tend to score lower than females on traits such as harm avoidance, reward dependence, cooperativeness, and perfectionism (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Moreover, they often exhibit fewer difficulties with emotional dysregulation compared to their female counterparts. Still, common traits shared across genders include low cognitive flexibility, perfectionism, high self-imposed demands, a strong need for control, and difficulty adapting to change (Bruch, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). These features often intensify at the onset of the illness and may become more pronounced as the disorder progresses chronically. In all the cases presented in this series, these traits were evident both before the onset of symptoms and throughout the course of the illness.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eSymptoms\u003c/h2\u003e \u003cp\u003eThe diagnostic criteria for Eating Disorders (EDs) do not differ between males and females according to international guidelines. The primary difficulty lies in the lack of recognition of EDs in males, a population traditionally considered to be at lower risk (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). With regard to \u003cb\u003epurging behaviors\u003c/b\u003e, males with Eating Disorders are less likely to engage in self-induced vomiting or laxative use. Instead, they more frequently rely on excessive physical exercise, a behavior that both reinforces traditional masculine ideals and aligns with a preference for increased muscle mass (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA widely accepted sociocultural framework explaining the development of EDs in males is the \u003cb\u003eTripartite Influence Model, adapted by Tylka\u003c/b\u003e. This model posits that while cultural beauty ideals for women have historically emphasized thinness, male ideals are more focused on muscularity. Some authors describe this phenomenon as \"\u003cem\u003einverted anorexia\u003c/em\u003e\", now formally recognized as \u0026ldquo;Muscle \u003cem\u003eDysmorphia\u003c/em\u003e\u0026rdquo; in international diagnostic systems. In this condition, males perceive their muscles as inadequately developed despite objective evidence to the contrary. The model theorizes that sociocultural pressures drive internalization of the muscular ideal, leading to body dissatisfaction centered on body fat. This dissatisfaction often results in dietary changes aimed at \u003cb\u003eincreasing muscle mass\u003c/b\u003e (also known as drive for muscularity) together with \u003cb\u003edrive for leanness\u003c/b\u003e (absence of body fat) such as elevated protein intake or even the use of anabolic substances (Lavender et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Nagata et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) (Richardson \u0026amp; Paslakis, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Franceschini \u0026amp; Fattore, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) (Upchurch, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) (Schmitt et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Tipically, this symptomatology was related to sports like halterophilia, but recently other sports such as cyclism are being affected too (Mazaraki et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Because these behaviors can easily be mistaken for healthy lifestyle choices, detection is often delayed. This delay exacerbates the individual\u0026rsquo;s suffering and contributes to the misconception that EDs are exclusively a female issue (Richardson \u0026amp; Paslakis, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this context, the clinical presentation of EDs in males frequently diverges from the traditional thinness-oriented model, shifting instead toward a \u003cb\u003emuscularity-oriented phenotype\u003c/b\u003e (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). As observed in our case series\u0026mdash;particularly Case 2 and Case 5\u0026mdash;the psychological drive is often centered on achieving a lean yet muscular physique, a duality that complicates early clinical recognition (Lavender et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This pursuit of muscularity is not merely aesthetic but is often a predictor of severe disordered eating behaviors, where the use of supplements and excessive training serves as a gateway to restrictive patterns (Nagata et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In this context, \u003cb\u003ecompulsive physical exercise\u003c/b\u003e (defined as a persistent need to engage in intense physical activity despite negative consequences) emerges as a primary compensatory mechanism and a tool for emotion dysregulation, especially in athletic or highly self-demanding profiles (Mazaraki et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). A noticeable \u003cb\u003echange in exercise patterns\u003c/b\u003e can precede any dietary changes and should be regarded as an early warning sign (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This pattern was evident in several cases within our clinical sample.\u003c/p\u003e \u003cp\u003eCrucially, the extreme physiological strain and nutritional deficit inherent in these behaviors lead to profound endocrine disruption. In the absence of markers like amenorrhea, clinicians must look toward the suppression of the hypothalamic-pituitary-gonadal axis, which manifests as erectile dysfunction or the loss of morning erections\u0026mdash;the biological male counterparts to female menstrual loss (Skolnick et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Although this symptom may not be applicable to prepubertal children, it represents the biological counterpart to female amenorrhea and underscores the profound endocrine disruption common to both genders. This absence of a clear clinical indicator in boys contributes to underdiagnosis and diagnostic delays in this population (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOther \u003cb\u003esomatic symptoms\u003c/b\u003e, common to both sexes, include cardiac abnormalities (bradycardia), electrolyte imbalances and gastrointestinal disturbances (Nagata et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In the absence of clear signs pointing to an Eating Disorder, these symptoms may be misattributed to unrelated conditions. Consequently, patients are often referred to other medical specialists, delaying appropriate psychiatric evaluation. Such delays increase psychological distress and heighten the risk of the disorder becoming chronic (Richardson \u0026amp; Paslakis, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). These features were present to varying degrees in the patients described in our case series.\u003c/p\u003e \u003cp\u003eFinally, it is important to highlight potential \u003cb\u003edifferences in psychiatric comorbidities\u003c/b\u003e. Males with EDs more frequently present with anxiety disorders or psychotic features, whereas affective disorders are more common in females with EDs (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) (Franceschini \u0026amp; Fattore, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). All of these symptoms are related to concern about their body image (Schmitt et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinally, \u003cb\u003egrowth stagnation in both height and weight\u003c/b\u003e should be considered a critical warning sign of an underlying Eating Disorder in boys. This may be one of the few indirect markers of altered eating and/or exercise behaviors in this population.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eDiagnosis\u003c/h2\u003e \u003cp\u003eAs discussed previously, there is a notable \u003cb\u003elack of diagnostic tools specifically designed\u003c/b\u003e for identifying eating disorders in males. Numerous studies have emphasized the need for assessment instruments that capture male-specific cognitive patterns, particularly those related to muscle mass development and muscularity-oriented body image concerns, rather than focusing solely on weight loss or the idealization of thinness (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) (Richardson \u0026amp; Paslakis, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Nagata et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The development and implementation of such tools would facilitate earlier and more accurate identification of eating disorders in male populations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eTreatment\u003c/h2\u003e \u003cp\u003eMen with Eating Disorders remain underrepresented in treatment samples included in scientific research (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Several barriers hinder their access to care, barriers that are especially pronounced among adolescents and young adults compared to preadolescents. These include stigma, lack of awareness of available services, limited information on recognizing clinical risk and insufficient knowledge on how to seek help, both individually and within the family context (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) (Richardson \u0026amp; Paslakis, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Franceschini \u0026amp; Fattore, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Nagata et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Additionally, many existing treatment approaches have been developed based primarily on female populations and often fail to adequately address male-specific needs. These include concerns related to masculinity, muscularity, male physiological symptoms and stigma. As a result, treatment frameworks may not fully resonate with male patients or their lived experiences (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo date, there are no empirically validated treatment protocols designed specifically for males with Eating Disorders. However, existing treatments are being adapted to better meet male patients' needs by incorporating discussions on stigma, muscularity-oriented body image concerns, and sex-specific physical and psychological presentations (Gorrell \u0026amp; Murray, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Ganci, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMore recently, a promising treatment paradigm, particularly for Anorexia Nervosa but applicable to other EDs, has emphasized the active involvement of the family in the therapeutic process. This family-based model empowers families to take an essential role in the patient's recovery process, moving beyond an individual-focused framework to a more systemic and supportive approach (Richardson \u0026amp; Paslakis, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Ganci, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEncouragingly, studies examining treatment outcomes in men who do engage with services suggest that remission rates are high and treatment efficacy does not differ significantly by gender (Brown \u0026amp; Keel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This finding underscores the importance of facilitating earlier diagnosis and improving access to gender-sensitive care, rather than modifying the core therapeutic principles themselves.\u003c/p\u003e \u003cp\u003eIn conclusion, our case series underscores that while the core pathology of EDs remains consistent across genders, the clinical phenotype in males is often masked by sociocultural ideals of muscularity and a lack of gender-specific screening tools. Increasing clinical suspicion in male patients with growth stagnation or compulsive exercise is vital to preventing chronicity.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWhile this case series provides valuable clinical insights into the presentation of Eating Disorders (EDs) in male children and adolescents, several limitations must be acknowledged:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eSample Size and Selection Bias\u003c/em\u003e: As a series of five clinical cases, the findings cannot be generalized to the entire male population with EDs. Furthermore, the cases were recruited from a specialized Care Unit, which inherently introduces a selection bias toward more severe and medically unstable presentations (e.g., severe malnutrition or bradycardia). This may explain the predominance of Anorexia Nervosa in our sample, contrasting with broader epidemiological data that suggests Binge Eating Disorder is more prevalent in males.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eRetrospective Nature\u003c/em\u003e: The data were collected through clinical history and retrospective review of medical records. This may lead to \"recall bias\" or the omission of certain longitudinal variables that were not systematically recorded at the time of the first consultation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eDiagnostic Tools\u003c/em\u003e: The lack of standardized, male-specific psychometric instruments during the initial assessment may have limited our ability to quantify specific symptoms like muscle dysmorphia or exercise-related body dissatisfaction with the same precision as weight-related concerns.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eFollow-up Period\u003c/em\u003e: Although the evolution of the patients is described, the follow-up period varies between cases. A longer longitudinal monitoring would be necessary to assess long-term remission rates and the risk of relapse specifically in this male cohort.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eSingle-Center Study\u003c/em\u003e: The findings reflect the clinical practice and demographic characteristics of a specific geographic area and a single healthcare facility, which may not represent the socio-cultural diversity seen in other regions.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEating Disorders demonstrate a female-to-male ratio of approximately 10:1, contributing to the underdiagnosis of these conditions in males. However, recent evidence suggests a progressive increase in incidence among males, at least within clinical populations. Therefore, pediatricians need to be trained and informed about early detection and treatment.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhile Binge Eating Disorder (ICD-11 6B82) is epidemiologically the most prevalent ED in males, followed by Bulimia Nervosa (ICD-11 6B81) and Anorexia Nervosa (ICD-11 6B80), clinical severity often leads to a higher representation of restrictive patterns in specialized units.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUnlike females, males with EDs are frequently motivated by a dual desire: reducing body fat while simultaneously increasing muscle mass. Diagnostic tools mes, therefore, be tailored to assess these specific muscularity-oriented concerns, rather than focusing exclusivelyon weight loss or thinness ideals.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCompulsive physical exercise and/or a suddenchanges in activity patterns often represent some of the earliest warning signs of an Eating Disorder in males, often preceding overt dietary restriction. Traditional compensatory behaviors, such as such as self-induced vomiting or laxative misuse, appear to be lees frequent in this group.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe absence of gender-specific physiological markers (such as amenorrhea) and the lack of observable androgenic alterations in prepubertal boys complicate early diagnosis. In this context, stagnation in height and weight should be regarded as a critical clinical \"red flag\" warranting immediate psychiatric evaluation. .\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIt is essential to develop gender-sensitive diagnostic instruments and validated treatment protocols, ultimately improving clinical recognition and long-term outcomes for this traditionally underserved population..\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCOMPETING INTEREST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eARTIFICIAL INTELLIGENCE (AI) USE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo AI software has been used to prepare the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Ruth Arias-Hidalgo, Covadonga Canga-Espina and Azucena Díez-Suárez. The first draft of the manuscript was written by Ruth Arias-Hidalgo and Covadonga Canga-Espina and all authors commented on previous versions of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAVAILABILITY OF DATA AND MATERIALS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatry Association. (2022). \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown, T. A., \u0026amp; Keel, P. K. (2023). 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Eating disorders in adolescent boys and young men: an update. \u003cem\u003eCurrent Opinion in Pediatrics\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(4), 476\u0026ndash;481. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/MOP.0000000000000911\u003c/span\u003e\u003cspan address=\"10.1097/MOP.0000000000000911\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrtu\u0026ntilde;o S\u0026aacute;nchez-Pedre\u0026ntilde;o, F. (2022). \u003cem\u003eLecciones de psiquiatr\u0026iacute;a\u003c/em\u003e (Editorial M\u0026eacute;dica Panamericana (ed.); Second).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichardson, C., \u0026amp; Paslakis, G. (2021). 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Tendencies of eating disordered behaviours in male content creators: a social media analysis. \u003cem\u003eJournal of Eating Disorders\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(1), 201. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s40337-025-01395-8\u003c/span\u003e\u003cspan address=\"10.1186/s40337-025-01395-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkolnick, A., Schulman, R. C., Galindo, R. J., \u0026amp; Mechanick, J. I. (2016). The Endocrinopathies of Male Anorexia Nervosa: Case Series. \u003cem\u003eAACE Clinical Case Reports\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e(4), e351\u0026ndash;e357. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4158/EP15945.CR\u003c/span\u003e\u003cspan address=\"10.4158/EP15945.CR\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUpchurch, A. (2024). \u003cem\u003eMuscularity oriented disordered eating and exercise in adult male exercisers: A quantitative analysis\u003c/em\u003e [Adler University]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.proquest.com/dissertations-theses/muscularity-oriented-disordered-eating-exercise/docview/3258801734/se-2\u003c/span\u003e\u003cspan address=\"https://www.proquest.com/dissertations-theses/muscularity-oriented-disordered-eating-exercise/docview/3258801734/se-2\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Eating Disorders, male Eating Disorders, Anorexia Nervosa, compulsive exercise, muscle dysmorphia","lastPublishedDoi":"10.21203/rs.3.rs-9428669/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9428669/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Eating disorders (EDs) are severe psychiatric illnesses associated with high morbidity and mortality. Traditionally, their strong association with the female gender has resulted in a scarcity of literature regarding male presentations. This disparity leads to limited clinical understanding, diagnostic delays, and a lack of gender-specific therapeutic guidance for the male population..\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription of the clinical cases\u003c/strong\u003e: We present a series of five clinical cases of male children and adolescents (under 18 years old) diagnosed with EDs and treated at our Child and Adolescent Psychiatry Outpatient Unit between 2022 and 2023. The cases highlight diverse presentations, ranging from severe restrictive Anorexia Nervosa with life-threatening malnutrition to exercise-focused compensatory behaviors and body dissatisfaction centered on muscularity..\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e: While sharing core features with female presentations, EDs in males exhibit distinct patterns, such as a drive for muscularity (\"inverted anorexia\"), compulsive physical exercise as a primary compensatory mechanism, and the absence of traditional physiological markers like amenorrhea. These factors often mask the disorder, leading to misdiagnosis or late intervention..\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Identifying male-specific \"red flags\"—including height/weight stagnation and obsessive exercise—is crucial for early detection. Further research is essential to develop gender-sensitive diagnostic tools and integrated treatment protocols to ensure high-quality, specialized care for this underserved population.\u003c/p\u003e","manuscriptTitle":"Beyond the Drive for Thinness: Clinical Characteristics and Diagnostic Red Flags in Male Pediatric Eating Disorders: A Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 14:00:22","doi":"10.21203/rs.3.rs-9428669/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1376d870-bfed-4b0d-8f47-2a985b6d5ce0","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-03T06:59:30+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-03T07:10:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 14:00:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9428669","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9428669","identity":"rs-9428669","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}