Anorexia Nervosa and Sexuality in Women: A Review

Journal of Sex Education and Therapy, 2000blu

Abstract

Patients affected by anorexia nervosa (AN) have difficulties expressing themselves both emotionally and sexually. Relational problems seem to have a multifactorial origin similar in its complexity to that of the pervasive eating disorder. Endocrine disorders, neurological disease, and genetic factors may cause anorexia, but psychological factors are supposed to play the prominent role.

Data in the literature do not support the evidence of psychopathology associated to AN so severe to deserve the first diagnosis, but psychopathological traits are almost always present. Anorectic patients show repetitive behaviors and perfectionism, responsible for rigidity and social introversion, that may worsen the cohort of clinical symptoms of AN. Problems in maintaining interpersonal relationships are part of a generalized emotional disturbance, where inadequate sexual functioning and conservative attitudes are only additional elements.

Most patients develop anorexia during adolescence. Those who became anorectic in adulthood report that their sexual functioning was normal before the illness. Therefore, most scientists believe that the altered balance of ovarian steroids and central neurotransmitters explains lack of sexual interest. In fact, endocrine and neuroendocrine alterations can be found in depressed patients again associated to loss of sex drive; in addition, according to some reports, they seem to precede malnutrition, apparently assuming a causative role that is not yet explained. This supports the hypothesis that difficulties of sexual functioning in AN patients have an origin as complex as the one of the eating disorders

Anorexia nervosa is characterized by a severe disturbance of the patient’s nutritional patterns, leading to excessive weight loss. AN represents a mental condition where psychiatric problems are intertwined with alterations of the whole endocrine system. Only a broad, multifactorial perspective can explain the full-syndrome clinical pattern (Becker et al., 1999).

The disorder rarely begins before puberty or in adulthood. Most often it appears in adolescence with rates of 0.5-1.0% for cases that meet full criteria, whereas patients with some but not all features are more common. The incidence of AN seems to have increased in the recent past. There is a higher risk of anorexia nervosa among the female relatives of patients. In fact, more than 90% of cases occur in females and there is limited information regarding the prevalence in males.

The individuals refuse to maintain body weight within minimal acceptable range for age and built, have disturbed body image and manifest intense fear of gaining weight, even if they are undernourished. The disturbance in the perception of body shape and weight is the essential feature. The weight loss is usually attained by reducing the total daily food intake, followed by the exclusion of perceived high calory food to end up with a very restricted diet. This is often accompanied by intense physical activity. Frequently patients tend to use laxatives and diuretics and to provoke vomiting to eliminate quickly what they ate.

Because the perception of body shape is disturbed, individuals feel fat even if some may realize that they are thin. The self-esteem of AN patients depends on their body image: losing weight is considered an achievement in self –discipline to be proud of . Weight gain is instead a terrible sign of loss of control.

Many individuals manifest signs of depression, social withdrawal, irritability, insomnia, and loss of sexual desire especially when really underweight. Patients may have social concerns such as eating in public, limited social spontaneity, inflexible thinking, and constrained emotional expression, and they may show signs of obsessive-compulsiveness mostly related to food: they think of food, collect recipes, or cook for others while dieting.

The above-mentioned clinical characteristics, together with amenorrhea, form the fundamental diagnostic criteria for AN enunciated by DSM-IV (1994).

Cachelin et al. (1998) observe that amenorrhea might not be a critical criterion to define AN. They object that anorectic, non-amenorrheic women share the same high levels of disturbance as women who meet full-criteria.

The origins of AN are not completely clarified as yet. Endocrine unbalance, neurological diseases and genetic factors are sometimes important, but in most cases psychological factors are supposed to be paramount. Body shape plays a crucial role in determining how attractive a person is considered by others and by herself. Thus, people of abnormal body size will be seen as sexually unattractive. If losing excessive amount of weight is related to sexual attitudes of young women is a puzzling question: in fact, the pursuit of extreme thinness constitutes an avoidance of attractiveness, which would in turn protect patients from the highly anxiety-provoking intimate relations. The intriguing possibility is that severe anorexia is a method for avoiding a sexual and mature role (Bancroft, 1989).

This is confirmed by the case analyzed by Laufer (1996) where the body metamorphosis at adolescence provoked intense anxiety and refusal to integrate the new sexual connotations within the previous childlike physical image.

According to Hick et al.(1999) AN adolescent females were likely to be inaccurate in the self assessment of their pubertal stage. When asked to determine their current and desired pubertal maturation stage using Tanner’s drawings. Subjects underestimated both breast and pubic hair development more than 50% of the times. In addition, data analysis showed that inaccuracy was inversely related to desire for sexual maturity, confirming the patients’ desire for an immature body.

Clinical data point out that body image disturbances are linked to pathological eating behaviors in a circular relation where esthetical dissatisfaction precedes disordered eating and influences the severity of food intake patterns. On the other hand, amelioration of an altered body image seems to be necessary to achieve an effective treatment.

The understanding of how the AN patient experiences her body is an important step. To accomplish the task, Probst et al. (1997) used a life–size screen where subjects and controls had to estimate the images of their bodies. The result was that both groups had no difficulties in estimating correctly their body size, and authors could not find a tendency to overestimation, that is supposed to be typical for AN. In addition, the discongruence between cognitive and affective body perception was surprisingly absent in the control group but also in the anorectics.

Ryle and Evans (1991) found that a negative connotation of the normal weight and overweight body was specific to ED subjects, but also that the underweight body was not positively perceived; in addition patients did not consider themselves as “sexual”, without evidence of family pressure against femininity or sexuality.

The hypothesis that body image distortion results from the need for control is tested by Waller and Hodgson (1996) who investigated whether the perceived capability of being in control over a task affects the body perception of ED and control women. Capability of control was manipulated with the administration of different levels of task difficulty. As a consequence, the distorted evaluation of body size became bigger when patients perceived the task as difficult. The authors hypothesize that patients seeing themselves lacking control over external events would focus on enhancing internal control, namely controlling their attitude towards eating and body image.

Cash and Deagle (1997) analyzed the different conclusions of a large number of studies of body image perception in anorexics and bulimics, where most researchers describe two pathological approaches to physical appearance: 1- perceptual body size distortion (patients estimate their bodies bigger than they are); 2-cognitive-evaluative dissatisfaction (patients are unhappy with their bodies).

As they report, some studies found these approaches modestly related to each other, whereas others revealed no association.

The performed meta analysis allows the authors to conclude that ED women have greater body dissatisfaction and distortion than controls and tend also to overestimate their size. Body image distortion does not reflect a perception deficit because patients estimate correctly neutral objects.

The complex attitude that ED women show towards their bodies is worth consideration because it represents the path toward acceptance or refusal of sexuality. In fact, the body image that each person has of him- or her- self plays a crucial role in the attitude toward sexual relations, and that has proven true for men and women, youngsters and elderly people. It is not surprising that anorectics have difficulties in expressing their sexuality or that the same difficulties will extend to their intimate relationships, thus making these individuals socially isolated, anxious, and emotionally constrained.

It has been repeatedly supposed that sexual abuse could be dramatically involved in the development of eating problems. The experience of being sexually harassed is unfortunately common to many (the reported rates are of 10-15% of women), but the conclusions of investigations of sexual abuse in the eating disordered population are not homogeneous and the idea of a direct link between harassment in childhood and eating problems has not been supported. Also, clinical observation tells us that being the victim of sexual abuse means to be at risk for a number of psychological problems like anxiety, depression, and poor sexual functioning, not only eating problems. To determine whether sexual abuse is related to the nature and severity of the eating disorder, Vize et al. (1995) compared incidence of reported sexual abuse in patients with anorexia nervosa, or bulimia nervosa, or depression, and a control group. The onset of the eating problem and the occurrence of any abuse were carefully dated. On individual interviews both ED and depressed patients reported higher rates of abuse than controls but did not differ from each other, nor were differences found between features of abuse (age, type, perpetrator) and psychopathology (anorexia, bulimia, depression). According to the authors the variability seen in the literature derives from differences in sampling and in the criteria used to define abuse, confirming that sexual abuse is a non-specific risk factor for the development of psychopathology.

Further observations come from Tice et al. (1989) who, during the course of therapy, noticed that patterns of eating behavior were used by patients as reactions to the assaults, intended to change the patient’s body image, or to deal with the repressed anger toward males. The authors conclude recommending that sexual issues be addressed early in treatment.

Their opinion is shared by Leon et al. (1987) who investigated a group of anorectics after hospitalization. The authors found that patients who had the most negative attitudes about sexuality, body image, and social relationships at the time of hospitalization had not improved significantly at follow-up and showed the greatest degree of general personality disturbance. Because of their findings, the authors suggest that sexuality and personality concerns be carefully dealt with in the treatment of AN.

Scientific studies proved that women with nutritional problems see themselves as having limited control over external events and over their own lives. One event particularly worth investigation is sexual abuse, as it has been linked both to eating disorders and to poor perception of personal control. To test the hypothesis that ED women will perceive lower control over their own lives if they had suffered sexual harassment Waller (1998) administered to women affected by anorexia or bulimia nervosa a battery of questionnaires and a psychosexual interview. In his group, women who reported sexual abuse had a lower sense of control than women without such experience. He also found that patients with more severe eating psychopathology saw themselves as less in control of their lives. According to the author’s remarks it remains to clarify whether the association of poor control and sexual abuse is specific to eating disorders or is common to other psychopathologies where issues of control are relevant.

To explore the role of stressful life events in the onset of AN, Schmidt et al.(1997) compared a group of ED patients with a control group. Subjects and controls were assessed to measure the occurrence of traumatic life events with a specific sexual meaning that could have triggered the disorder. They found that stressing experiences are common to all, but ED patients reported more traumas characterized by a sexual connotation or concerning family and friends. Subjects and controls did not differ in the occurrence of at least one stressful event, but ED patients had experienced major coping difficulties. While most serious problems concerned family and close friends for all groups investigated, AN patients had significantly more stressful events related to sexual matters. The authors conclude that problems with sexuality may be specific in triggering the onset of AN.

Even if stressful events are reported to precede the onset of eating disorders, their incidence is not dramatically different from that seen in healthy women.

We may speculate that patients have a diminished capacity to bear the anxiety provoked by “any stressor” and that their compulsive nutritional behaviors are negative ways of avoiding stress rather than positive maneuvers to cope with it (May, 1977 ).

To investigate the effects of stress and the ways of coping with it of anorectics and bulimics as opposed to controls, Troop et al. (1994) used a number of questionnaires concerning depression, eating disorder symptoms, and coping. Given that effective coping strategies and seeking support from others are associated with low anxiety and depression, while avoidant behavior and denial are associated with difficulties in dealing with stresses, the authors’ hypothesis was that eating disordered patients would be more avoidant and would use less social support than controls. Their data confirmed the expectations: AN and BN patients used more avoidance and less social support than controls, supposedly because they are socially anxious, fear intimacy and maintain conflictual relationships: this may reduce their willingness and capability to ask for support. The authors conclude recommending a problem-solving component to be included in the treatment of ED.

In a later work Troop et al. (1998) investigated the hypothesis that ED women were less effective in coping with stresses than healthy women. Their results were that AN and BN patients showed avoidant behavior and received less crisis support. In details, bulimics received less support from their significant others than anorectics and controls. Authors again conclude in recommending treatment to improve the patients’ coping abilities.

To investigate the support network of ED patients, Tiller et al. (1997) used a questionnaire where patients and controls had to rate their important relationships on measures of emotional and practical support. Both AN and BN patients reported lower levels of emotional and practical support than the comparison group. They also had lower ideals for support than the controls. This could come from the negative experiences of childhood care that may have decreased expectations of emotional interaction. In addition, AN patients nominated fewer support figures than the comparison group, especially from outside the family of origin, and were less likely than BN patients to receive support from a spouse or partner. This confirms the findings of Troop et al. and is in keeping with the less positive attitude toward sexuality and intimacy reported by anorectics as compared to bulimics.

Inevitably, ED patients show constant problems related to their weight, shape, and body image. According to Gupta et al. (1995) they report a sense of deprivation of hugging and cuddling in infancy. Secure holding, touching, and caressing are essential to the development of positive body image in children. It is plausible that a causal relationship links the sense of touch deprivation in infancy and the altered body perception at a later time in these women. To verify these observations the authors examined the perception of touch deprivation among ED patients and controls. According to their data, not only patients were obviously dissatisfied with their body perception, but reported more touch deprivation than the controls. This supports the hypothesis that tactile nurturance in infancy is important to developing and maintaining a positive body image.

Bastiani et al. (1995) confirmed that anorectics are perfectionist and that they feel that their perfectionism is self imposed and not a response to the expectations or requests of others. It persists after weight restoration together with other typical behaviors like rigidity, social introversion, and overly compliant behavior. All may be responsible for resistance to treatment and relapses.

To differentiate positive and negative aspects of perfectionism the terms “normal” and “neurotic” are used. In fact, it can account for some very desirable characteristics that ensure satisfaction and enhance one’s self-esteem; or it can represent the negative attitude of striving for goals that are painstaking and out of reach, bringing disappointment and feelings of inadequacy. Data in the literature confirm that both positive and negative aspects of perfectionism are correlated with attitudes symptomatic of eating disorders.

To clarify the influence of personality factors, such as perfectionism, in the genesis of eating disorders Davis (1997) administered a questionnaire booklet, comprised of personality scales, to a number of patients. Her task was to test if positive and negative dimensions of perfectionism were related to nutritional disorders. The author found that the normal and the neurotic components of perfectionism were inversely related to body self-esteem: normal perfectionism was related to body esteem but, as neurotic perfectionism increased, body image disparagement was most pronounced. Dissatisfaction with one’s body image seems to worsen when a person sets too high standards for herself and experiences strong fear of failure. The author concludes noting that such psychological profile is very common among people with nutritional problems where self starvation and poor body image derive from rigid and unrealistic esthetical aspirations.

Hewitt et al. (1995) explored the association between perfectionism and eating disorder symptoms in college students not affected by nutritional problems to assess if and how attitudes and behaviors of both disorders were associated in a non clinical population. The authors found that self-oriented and social perfectionism significantly correlated with the Eating Attitudes Test total and dieting scores. Self-oriented perfectionism was linked to concerns with being thin and dieting behavior, while socially prescribed perfectionism was related to both eating behavior (concerns about appearance) and self-esteem, motivated by the need to conform to “models” perceived as demanded by others. This confirms the link between eating disorders and different aspects of perfectionism.

A family pattern involving the female relatives of ED patients is commonly observed. It is explained by the exposition to similar social influences, genetics, or psychological traits running in the family.

To explore familial tendencies and psychopathological traits influencing nutritional attitudes Steiger et al. (1996) examined a large sample of families, divided into “eating disordered”, “normal control “, and “psychiatric control” groups. The grouping was intended to facilitated comparison between traits and attitudes that may be specific (and presumably causal) to nutritional problems. The results indicate that eating concerns are independent from generalized psychopathological traits. In this sample, variations of general psychopathology were represented by two trait dimensions: one characterized by narcissistic traits and affective instability (which the authors labeled Dramatic-Erratic Traits); the second represented by compulsivity and emotional constriction (labeled Obsessive-Compulsive Traits). Both are supposed to be inheritable, so the data presented in this paper suggest a family tendency. The transgenerational correspondence was evident for the characteristics labeled “dramatic-erratic traits” and less evident for “obsessive-compulsive traits”. In addition, eating concerns and symptoms were gender-dependent: the attitudes of daughters (patients and sisters) corresponded to those of their mothers but not to those of their fathers. The analyzed traits and attitudes seem indeed to follow family patterns, but will not be sufficient to trigger the development of nutritional problems in offspring. The authors discuss that exposure to parents’ eating concerns and psychopathological traits will influence the children’s attitudes, but to develop a clinical disorder the child will need to be additionally “vulnerable” in the form of genetic factors, specific family or social pressures, or combined effects of traits carried by each parent. They conclude that although parent-child correspondence of eating attitudes and psychopathological traits exist, it seems inadequate to explain the development of a full disorder.

When the psychosexual attitude of AN adolescents is examined, Beumont et al. (1981) report that patients have little information on sexual matters included contraception. In addition, while some wished they knew more, other clearly avoided sexually-related material. Although most patients stated they wanted to marry they were ambivalent towards menstruation, pregnancy, and common sexual behaviors like masturbation or premarital intercourse. Most patients considered their actual sexual experiences in a negative, unfavorable way, or had guilt feelings. The group as a whole was much less experienced than other girls of similar age.

When young bulimics were investigated on their attitude toward sexuality (Abraham et al., 1985), they were likely to have experienced a broader range of activities than anorectics. They had orgasm on masturbation, experimented with anal intercourse and considered their libido as “above average”. As a negative aspect, they felt unattractive when they reached a certain weight and tended to avoid social and sexual contact.

ED patients are supposed to have sexual difficulties, but it is not easy to determine if the assumption is correct and, in case it is, which are the psychological determinants responsible for it. The Eating Disorders Inventory (EDI; Gardner, Olmstead, and Polivy, 1983) is a questionnaire formed by eight sub-scales and specifically constructed to analyze cognitive and behavioral characteristics of anorectic patients; its administration can be of help in understanding their attitudes towards sexuality.

The scales related to sexual expressions are: n°6 “Interpersonal Distrust” that measures the difficulty to form intimate relations; and n°8 “Maturity Fear” related resistances to assume the adult role.

If the hypothesis of a relationship between anorexia nervosa and sexual inadequacy is correct, the scores obtained on scales n°6 and n°8 should differ significantly from those of controls. In fact, when Santonastaso et al. (1995) validated the Eating Disorder Inventory for the Italian population, they observed that controls differed clearly from both anorectics and bulimics on the scales mentioned before and on the scale n°5 “Perfectionism”. It is worth noting that scales n° 6, n°8, and n°5 do not differentiate among subgroups of eating disorders, while the remaining subscales do. It can be explained by the fact that perfectionism, interpersonal distrust and maturity fear are psychological attitudes common to all patients affected by an eating disorder, whereas the remaining ones describe characteristics that each subgroup presents in different percentages.

Further support for these results is given by Wiederman and Pryor (1997) who observed that none of the E.D.I. subscales can differentiate the subgroups of alimentary disorders. The authors observe married and single women to find attitudinal differences that can be linked to their marital status. Their efforts were unsuccessful in the sense that they could not establish correlations between any of the subscales and the fact the a patient was alone or in a committed relationship. In other words, marital experience was unrelated to any of the scores obtained in the group of women with anorexia nervosa. The data are in contrast with a “common sense thinking” because it would seem quite obvious that women in committed stories had better capability to maintain intimate relationships functional to the adult role. These apparently contradictory data can be justified by the observation that difficulties and uneasiness are inevitably built in the personality of people affected by eating disorders and cannot be changed even by a positive and stable heterosexual relationship.

On the same line Sexton et al. (1998) investigated the prevalence, stability, and clinical correlations of alexithymia in ED patients and controls. Alexithymia is defined as the very specific difficulty to distinguish different emotional states or between emotions and bodily sensations; it is usually associated with impoverished or constrained production of fantasies. Their results indicate that the subscale Interpersonal Distrust (related to alienation, difficulty to form intimate relations, resistance to express thoughts and emotions) can separate patients from controls. It is also strong enough to differentiate between subgroups, being very high in anorectics. We must report that these data, although interesting, are not consistent with the results obtained by the scientists presented before.

The above mentioned studies report of a pattern of psychological distress in anorectics that explains the difficulties these women have to establish sexual and interpersonal relations.

Given the complex, multidimensional nature both of the eating disorders and of the interpersonal difficulties it is arduous to say which influences the other. Most likely they are connected to form a clinical pattern of generalized emotional disturbance. O’Mahony et al. (1995) investigated three groups of women: the first was formed by anorectics; the second by models and dancers, obviously interested in their physical appearance; the third one by “normal” women, to study how attitudes toward food and interpersonal relations are connected. Their data show clear differences between the anorectics and the women belonging to the remaining groups, with the degree of anorexia being directly related to the difficulties in forming positive social contacts. The authors conclude that problems in social interaction are not a direct cause for anorexia nervosa; but when anorexia goes beyond a certain degree of severity the two pathological behaviors become interrelated and their reciprocal dependence is as strong as the alimentary problem is severe.

Since the anorectics have difficulties in establishing interpersonal relations, it will be difficult for them to stay in romantic relationships. According to Rothshild (1991) these patients show sexual functioning and gratification below the average scores of validated questionnaires, and feel uneasy in respect of their body image.

According to Simpson and Ramberg (1992) patients show anxiety or even aversion to sexuality, are disturbed by nudity, deny sexual desire, are anorgasmic, and avoid sexual activity even when they live in a romantic, stable relationship.

The vast majority of anorectic women who became sick in adulthood recognize their sexual difficulties but state clearly that their sexuality was adequate before the disorder (Tuiten et al., 1993). The information is convincing enough for the authors to elaborate the hypothesis that the deterioration of sexuality is a response to the endocrine unbalance typical of Anorexia Nervosa. The reduction of the circulating levels of ovarian steroids is known to have a negative influence on sexual desire and fantasies, even if the expression of sexual interest in humans is inevitably linked to social and relational factors and cannot be reduced to the mere response to the plasma hormone concentrations. Still the importance of a normal healthy endocrine functioning cannot be dismissed. The authors give positive support to their theory by administering questionnaires for the retrospective evaluation of the attitude towards sexuality to anorectics and matched controls. Their results show evidence that the premorbid sex life of the anorectics was absolutely similar to that of the controls in respect of sexual desire, eroticism, intimacy, and interest. Salient differences appear only later.

According to Morgan et al. (1995) and Wiederman et al. (1996) anorectics and bulimics have different attitudes towards sexuality, and specific characteristics can be attributed to each of the two subgroups. In their studies anorectic women seem to have narrower capability of sexual expression, are or have been in romantic relations less often, have a poorer image of themselves, do not consider themselves as possible object of desire, do not engage in self-pleasuring, refuse oral sex , and are quite ignorant about contraception. On the contrary, bulimic women are happier about themselves, engage in sexual activity more frequently and, in general, are more satisfied with their relationships.

On a later project Wiederman and Pryor (1997) assessed that body dissatisfaction in bulimics was related to low incidence of masturbation and to dissatisfaction with one’s sexual life. It is difficult to draw conclusions from these data. In fact, the authors do not explain their findings nor they hypothesize causal relations for the differences they describe.

It is generally accepted that people with sexual inadequate or avoidant behavior are likely to present a cognitive negative attitude where they fixate on their bodies or body parts.

Faith and Schare (1993) investigate a large group of university students (males and females) by means of self-administered questionnaires to examine this phenomenon. Items like body image, sexual knowledge, sexual attitude, and psychological adjustment to sexual experience were investigated. The authors concluded that only two variables significantly predicted sexual frequency for both genders: positive or negative self-appreciation of body image, and liberal or conservative sexual attitude. Although the authors did not study ED patients, in our opinion their findings help understand the mechanism of sexual inadequacy in both anorectics and bulimics.

The fact that anorectic patients show aversion toward sex is not surprising given how they relate to their own bodies. Many of the studies mentioned before report how deeply AN patients are concerned and displeased with their physical appearance. For the sex therapist that would be enough to generate anticipatory negative feelings (that is “spectatoring”, according to Kaplan, 1974) that will in turn interfere with desire. The picture becomes ever clearer if we consider that sexual aversion and phobia are believed to strike emotionally vulnerable individuals who will not be able to sustain psychodynamic and relational stressors in the way that “biologically normal” people would (Kaplan, 1987). In this respect, Stuart et al. (1986) failed to shed light on the psychobiological characteristics of women who did not experience sexual drive. In our opinion, their pool of patients was not homogeneous enough to allow clear cut results.

As mentioned before, anorexia nervosa can occur, although not so often, in adulthood and consequently may strike married women and create distress in the couples functioning.

Van der Broucke et al. (1994-a) hypothesize that marital communication in these couples would be blocked by the patient’s inability to express her feelings. The authors conceptualize a distinction between couples where a spouse was sick before the marriage or became ill at a later time: an ED patient may enter and maintain a marital relationship in a certain way, whereas the characteristics of couples struck by a later onset are supposed to be completely different. Contrary to expectations, their findings did not distinguish between early or late onset. When compared with not ED couples, subjects show a “flat” way of communicating, meaning that they used less criticism or disagreement, and their interaction was less destructive in case of conflicts. On the other hand, they used less positive comments which contributed to the impression that ED couples had distant and less rewarding interactions.

Van der Broucke et al. (1994-b) investigated the supposed psychological distress of the husbands of anorectic women, assuming that there would be a correspondence between the wives’ disorder and the men’s emotional state. Again contrary to expectations, the study did not show more symptoms of distress in the spouses of anorectics than in husbands of happy marriages, nor there was a correspondence between the psychopathological profiles of anorectics and those of their husbands. The authors conclude that the findings, although not expected, are in close agreement with those reported about husbands of agoraphobic females.

Anorexia nervosa has been interpreted as a refusal to become a grown woman: it is worth noting that some of its characteristic behaviors and attitudes are functional in keeping the patient sheltered from the gratification and responsibilities of adulthood, such as sexuality and procreation. It is not only a matter of repudiation of sex in terms of interest, adequate behavior, or capability to form love relationships that results in major interference with reproduction. It is that the physiological basis of fertility is shut down. In fact, anorectic females show circulation levels of steroid hormones at prepubertal or pubertal levels that become manifested in the epiphenomenon of amenorrhea (Mogul, 1989).

Amenorrhea may precede or follow weight loss, or it may become manifested simultaneously with the typical anorectic behaviors. In addition, amenorrhea may persist even in cases where the patient increases her body weight to normal levels. Weight and fat mass gain are usually associated to return of regular menses, but not in all patients. A review of the recent literature on this topic by Golden et al. (1994) reached the conclusions that a weight gain of 90% of the standard body weight for age and built is a necessary condition for the return of menstrual cycles, regardless of the amount of fat mass; nevertheless, not all the patients who reach that weight will menstruate.

According to Eckert et al (1995), who followed for ten years a group of anorectics in hospital treatment, 65% of the whole sample observed menstruated spontaneously within the 10 year observation period. Of them, 35% had menses in the first year and 85% was menstruating within 5 years. The remaining 15% had regained their cycles by the end of the ten years. The authors observe that increased body weight had to be maintained between 1 to 72 months before the menses returned.

In this regard, Copeland et al. (1995) point out that psychological and biological factors, correlated to each other, may influence the amenorrheic status, beyond body weight and nutritional conditions.

Among the biological factors, leptin (a hormone produced by the ob gene in the adipocyte) is hypothesized to have a role in the regulation of fertility, related to the amount of body fat mass. Circulating levels of leptin are reduced in patients with AN, and this abnormality is closely correlated with fat mass (Grinspoon, 1996).

The endocrine and neuroendocrine alterations found in AN are caused by malnutrition, but it is possible to hypothesize that some of them have a predisposing or even causative role in the pathogenesis of the illness.

The origin of the neuroendocrine alterations observed in anorexia is still unclear.The main question is whether they are expression of hypothalamic or superhypothalamic dysfunctions (primitive or secondary to the psychological impairment), or they follow malnutrition and weight changes , or alternatively they represent the effect of psychological, nutritional, and metabolic factors that are reciprocally connected. It is also possible that one or more of these factors selectively modifies neuroendocrine transmission. However, conclusive data are lacking and the hypothesis is by now only speculative.

Many clinical manifestations described in AN are not specific of this disorder; in fact, some are found in subjects suffering for malnutrition of any origin, while others are similar to those observed in affective disorders.

The hypothalamic-pituitary-gonads axis in anorectics shows a functional regression to prepubertal or first puberal stages; such biological regression ideally correlates with a regression of the psychological status.

In conclusion, we can say that anorexia nervosa is a multidimensional entity formed by a wide variety of organic, psychodynamic, and endocrine disorders. The different roles that neuroendocrine alterations and behavioral abnormalities have in promoting or maintaining the typical cohort of organic and psychological symptoms are, in our opinion, impossible to differentiate. In fact, many of these symptoms (sexual attitudes in the first place) are integral to anorectic behavior, or secondary to weight loss and depression.

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