In clinical practice, male athletes with anorexia nervosa often present with high levels of discipline, performance, and apparent psychological control. These features can obscure underlying pathology and contribute to delayed recognition. Although eating disorders have historically been conceptualized as predominantly affecting women, there is now substantial evidence that men, particularly athletes, represent a clinically significant and underdiagnosed population.1,2
In male athletes, anorexia nervosa involves restricted intake leading to significantly low body weight, intense fear of weight gain or persistent behaviors preventing weight gain, and disturbed body image, self-worth overly tied to weight or shape, or persistent failure to recognize the seriousness of low weight.3 Male athletes occupy a unique intersection of risk, where performance demands, body composition pressures, and cultural norms converge. For clinicians, this creates diagnostic challenges that require heightened awareness of sex-specific presentations and sport-related risk factors.4,5
Epidemiology and Underrecognition
Eating disorders in males have been historically underrecognized, in part due to earlier diagnostic frameworks and persistent gender stereotypes.1,2 Epidemiologic data now suggest that men account for a meaningful proportion of eating disorder cases, with higher risk observed in athletic populations.5,6
Prevalence of eating disorders in adult male elite athletes has been reported at up to 32.5%, with wide variation by definition and sport, though anorexia nervosa is specifically lower. Some adult male elite athlete populations demonstrate higher rates of eating pathology compared with nonathlete controls, particularly in weight-sensitive sports, highlighting the type of sport as a significant risk factor.5 Despite this, male athletes are less likely to be identified, referred, or treated. Delayed diagnosis is common and contributes to increased medical and psychiatric morbidity.1,4
Clinical Presentation: Key Differences in Males
Male patients are more likely to:
Emphasize leanness or muscularity rather than thinness2Have a history of higher premorbid body weight2Exhibit less overt verbalization of body dissatisfaction1,2Present later in the course of illness1
In athletes, these features may be further masked by sport-specific norms. Restrictive eating, excessive exercise, and rigid routines are often interpreted as discipline rather than pathology.4,5 This can delay clinical recognition until medical complications or performance decline emerge.4
The Role of Sport-Specific Risk
Certain sports place athletes at increased risk, particularly those emphasizing weight, aesthetics, or endurance.5,6 These include:
Weight-class sports (eg, wrestling, boxing)5,6Endurance sports (eg, distance running, cycling)5Aesthetic sports (eg, gymnastics, bodybuilding)5
In these contexts, body composition is often directly linked to performance or selection, reinforcing behaviors that may overlap with eating disorder pathology.4,5,7
It is also critical to distinguish anorexia nervosa from relative energy deficiency in sport (REDs) and subthreshold disordered eating. Anorexia nervosa is defined by specific diagnostic criteria.3 REDs involves health impairments resulting from prolonged or severe low energy availability and can occur with or without an eating disorder, including through unintentional underfueling. Anorexia nervosa and REDs may coexist, and they are not distinguished simply by the degree of cognitive distortion or psychological impairment.8
Barriers to Diagnosis
Several factors contribute to the underdiagnosis of anorexia nervosa in male athletes:
1. Atypical Presentation
The focus on muscularity and performance may obscure classic signs of weight and shape concern.1,2
2. Normalization Within Sport
Behaviors such as caloric restriction, dehydration, and overtraining may be reinforced by coaches, peers, or competitive demands.4,5,7
3. Stigma and Gender Norms
Eating disorders remain widely perceived as a female condition, leading to reduced help-seeking and underreporting among males.1,2
4. Limitations of Screening Tools