Preteen Boys,Body Image,and Eating Disorders

Introduction

Over the last four decades, both public and academic attention have focused on the incidence of anorexia and related eating disorders for girls and women. In recent years, increasing attention has been paid to how particular ideals of the male body have been implicated in bodywork practices for boys and men. Although most of this attention has pointed to practices which have been designed to build a muscular “cut” body, including obsessive bodybuilding and steroid use (Frost 2003; Stibbe 2004), research has also pointed to increasing incidences of eating disorders for boys and men (Madden et al. 2009; Micali et al. 2013).

As an extension of the public and academic concern about those practices related to body dissatisfaction for both women and men, there has been a tendency to attribute the same relationship between social ideals and eating disorders to eating disorders among young children (specifically, preteen boys and girls). Although we have no argument with the considerable evidence that points to the incidence of eating disorders in children and, more specifically for this article, preteenage boys (e.g., Equit et al. 2013; Hatmaker 2005; Madden et al. 2009; Nicholls, Lynn, and Viner, 2011; Pinhas et al. 2011; Spiel, Paxton, and Yager 2012), what we do challenge is the ways in which a simple relationship between body image and eating disorders has often been assumed in media reports for this age-group.

While the research literature points to a much more complex picture (e.g., Equit et al. 2013; George and Franko 2010; Goncalves et al. 2012; Madden et al. 2009), popular media accounts of eating disorders in preteen boys tend to produce an overly simplistic and homogenized picture of boys succumbing to social pressures to conform to an idealized masculine body image, particularly as this is presented in advertising, film, and television. Such an account is not helpful to parents and clinicians who are attempting to understand boys’ disordered eating, especially when such accounts fail to resonate with their own experiences. Such accounts may also lead to simple interpretations and education programs that fail to take into account the complexities of the problem for individual children.

In the first part of this article, we demonstrate how the idea, that boys’ eating disorders are simply the consequence of boys’ unhappiness with their bodies generated through comparisons with ideal male bodies, is constituted in popular discourse. In the second, we use biographies generated from interviews with preteen boys who have been diagnosed with an eating disorder and with their mothers to trouble the certainty with which this popular discourse is recited to constitute a particular explanation of “eating disorders” among preteen boys and to provide a more critical and nuanced reading of the problem.

How Truths Come into Play

Media reporting provides ways in which claims to truth, which resonate with popular ideas/values, can be reiterated without having to prove or justify such claims. This echoes what Butler (1993, 21) describes as the “ritualized repetition” that operates to produce certain social norms and to stabilize their actual effects. Butler writes of the “reiterative power of discourse to produce the phenomena that it regulates and constrains” (p. 2). In this case, explanations for boys’ eating disorders draw on a combination of two now well-established discourses that have the imprimatur of medical and academic authority. The first and oldest explains anorexia and bulimia in young women as the effect of body dissatisfaction in relation to social ideals. More recently, a similar discourse has been used to explain similar phenomena for young men (Ricciardelli and McCabe 2004). It has not been too great a step to take these much recited explanations and apply them to explain eating disorders in preteen boys. In doing so, preteen boys are attributed with forms of masculine consciousness, previously associated with teenagers and men. Their disordered eating is explained as attempts to shape their bodies to make them more attractive in keeping with socially valued forms of masculinity.

As feminists and sociologists, who have lived and worked with such explanations for sometime, we were also attracted initially to these explanations for a diagnosis of an eating disorder in the children we recruited for our study. However, listening to their stories disrupted our own predictions and prompted a concern to trouble the linearity of such explanations. Although there were certainly references in the children’s talk to their unhappiness with their bodies, these were never juxtaposed with references to male bodies sourced from the media, film, or the Internet. Rather as we illustrate subsequently, their references to their bodies were very diverse and contingent on the boys’ circumstances, particularly their ages and the ways in which their disordered eating manifested. Our purpose in this article is to use their stories to “trouble” the boys/body image/eating disorder discourse that is currently promoted in the media. We examine its particular inflections and the authorities on which it selectively draws, and consider some of the implications for those whom the discourse most effects—boys, their parents, and health professional and health educators.

Boys and Eating Disorders: The Research

Most of the past and recent research on eating disorders has focused on young women (e.g., Brown and Slaughter 2012; Evans et al. 2013). The dominant clinical and theoretical frameworks informing research into eating disorders are grounded in the experiences and presenting symptoms of girls and women and are not suitable for the diagnosis of boys and men (Lock 2009). As a result, it is possible that the specificities and prevalence of eating disorders in boys have been overlooked and underestimated. There have also been few studies that have differentiated preteen boys from more generalized groups including adolescent and young adult males, males across the spectrum, children and adolescents, and young people of both genders. This raises some methodological questions while at the same time making it difficult to establish accurate information specifically about preteen boys and eating disorders. Nevertheless, we have located and drawn on research literature pertaining as singularly as possible to preteen boys, as this was the group who featured in our own research. In one such study, Madden et al. (2009) collected nationally representative data on Early Onset Eating Disorders (EOEDs) among five- to thirteen-year-olds being treated by child health specialists across Australia. Of the 101 cases collected, 25 percent were boys. In this study, an EOED was defined as “determined food avoidance plus weight loss or a failure to gain weight during a period of growth, in the absence of an identifiable organic cause” (p. 410). Body image perceptions were notably not part of this definition of eating disorders.

A pediatric surveillance study in the United Kingdom (Nicholls, Lynn, and Viner 2011) identified 208 reported cases of children with a diagnosed eating disorder, of which 37 (18 percent) were boys. The most common diagnosis for the whole cohort (43 percent) was for Eating Disorder Not Otherwise Specified (EDNOS). There was also a high proportion (41 percent) of psychiatric comorbidity, and psychiatric illness within the family (44 percent). Another recent Australian study (Bayes and Madden 2011) investigated ten boys with a median age of just under thirteen, all of whom had been diagnosed with either anorexia nervosa or an EDNOS. These boys engaged in food avoidance or restrictions, and often had comorbid psychiatric illnesses such as anxiety disorder (70 percent) and depression (40 percent). This was one of very few biomedical studies that focused exclusively on boys. All of these studies draw similar conclusions to those of Bravender et al. (2010), which pointed to the potentially more severe and contracted consequences of various eating disorders in children and youth, and thus the need for closer monitoring, along with effective and early intervention. None of these studies and reports suggest a cause for eating disorders in children, rather they recognize the complex, multifactorial nature of eating disorders in children, and the need to address this growing problem with respect to these complexities.

Popular Media Coverage of Boys with Eating Disorders

The media reporting of the research on the increasing incidence of eating disorders and body dissatisfaction among boys, teenagers, and young adults (Australian Institute of Health and Welfare [AIHW] 2013) ignores the complexity evident in the research. Much of this reporting attempts to counter the popular understanding of eating disorders and body image problems as issues only pertinent to girls and young women (e.g., Nazor Hill 2012; Ricciardelli 2012) However, it continues the metanarrative that girls’, and now boys’, eating disorders are a result of girls’, and now boys’, unhappiness with their bodies. Such unhappiness is in turn attributed to pressures to emulate the idealized and unrealistic images in film, television, modeling, and advertising (e.g., Hood 2003). For boys, these unrealistic expectations are realized as the sculpted, lean muscular clean (hairless) body (Ricciardelli 2012).

There is support in the research literature both from a sociological/cultural perspective and from psychological studies for these conclusions, although importantly for our argument most of this literature refers to teenage boys or older. Although some of this research suggests that boys may be dieting to produce a lean appearance (Grogan and Richards 2002), other research points to how teenage boys are trying to put on weight (O’Dea and Rawstone 2001) or resort to specialized dieting, exercise, and gym training together with (sometimes) the use of anabolic steroids to improve their muscle bulk (Frost 2003). These trends certainly point to the way men are becoming more preoccupied with body image and increasingly dissatisfied with their physical appearance (Gregor 2004), and we do not take issue with this position. However, the research conducted with teenage boys and men produces a compelling metanarrative that is taken up to explain boys’ eating disorders in terms of similar social pressures. What we challenge here is this the way eating disorders are so easily juxtaposed with preteen boys’ dissatisfaction with their bodies caused by idealized media images of masculinity.

One example of this juxtaposition is a newspaper article, “Pressure to be perfect means more boys are getting eating disorders”, in The Times (syndicated to The Australian). The article reports on a major UK study comparing the incidence of eating disorders for males and females aged ten to forty-nine years between 2000 and 2009. In the article, the journalist claims that “hundreds of young boys are developing eating disorders every year and experts say that pressure to look perfect at a younger age is partly to blame” (Smyth 2013, para. 1). Although the research reported in this article does state that the incidence of eating disorders among boys has increased significantly from 2000 to 2009, it is specifically the diagnosis of EDNOS that has increased (Micali et al. 2013). EDNOS is a category in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) designed to cover “atypical eating disorders,” that is, eating disorders of a clinical severity that do meet all of the criteria for anorexia nervosa or bulimia (Fairburn and Bohn 2005). This category has now been removed from the DSM-5, the category avoidant/restrictive food intake disorder (ARFID) added and the criteria for anorexia revised (American Psychiatric Association Division of Research 2014). Anorexia nervosa is now defined as a condition “which primarily affects adolescent girls and young women, is characterized by distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat” (p. 414). The new category of ARFID requires substantial weight loss but does not require “a distorted body image” (American Psychiatric Association 2013b).

In the media report of Micali et al.’s study, there is no speculation beyond changes in diagnosis as to why there has been an increase in diagnoses of eating disorders among boys. Indeed, the lead researcher on the study, Dr. Nadia Micali, points out that “The reality might be that boys have more eating problems early on in childhood and early adolescence that are not the common ones of anorexia and bulimia … among boys, similar numbers in the 10-14 [year old] category were developing problems that did not fit neatly into traditional categories” (quoted in Smyth 2013, para. 7). This comment reflects the subtleties, complexities, and even contradictions that were evident in our own research. These subtleties and complexities, more typical of rigorous research, are often overlooked when data are transmitted through popular media.

In another example, drawing on a different study, a commentator on the daily national Australian Broadcasting Corporation (ABC) online news program The Drum states that “the picture is worse for Australia; horrifically, one in four children and one in ten adults with anorexia nervosa is male” (Bain 2012, para. 3). Male eating disorders are declared “the elephant in the room—and it is an increasingly large elephant representing an increasingly skinny population of young males” (para. 6). Without any direct evidence, Bain claims that “the waifish emo and hipster subcultures have led to anorexia nervosa and bulimia nervosa” (para. 9). Bain rails against “the unhealthy aesthetics [that] are percolating into the mainstream media and filtering down to suburbia” (para. 11).

As pointed out earlier, we have no argument with the evidence that young men are increasingly body conscious and are often engaging in damaging practices to achieve their desired bodies, nor that this might be affecting boys in their early teens. What we do have issue with is the easy slippage from teenage boys to preteen boys, for whom we argue the issues may be different. We also take issue with the singular focus on idealized bodies in the mass media and the lack of attention to other social sources from which boys might derive anxieties about their bodies, such as the widespread focus on obesity and the social abhorrence of fat in any form. For example, a series of studies of primary school children’s meanings of health point to the children’s almost unanimous association of health with eating the right foods and exercising, and the equating of health with appearance—that is, “looking” a healthy weight (Burrows 2008; Harwood 2012; Wright, Macdonald, and Groom 2003; Wright and Burrows 2004). Although it is hard to attribute specific sources to these ideas, given their ubiquitousness in social interactions, the children in these studies pointed to their parents and their schools as the major sources of information about how to be healthy—that is, information about what to eat and what not to eat and how much exercise they needed to maintain a healthy weight.

In further support of this position, a study by Grogan and Richards (2002) of boys and older males ranging in age from eight to twenty-five years highlighted the prominence of an obesity discourse in the talk of the boys and men in their focus groups, which grew out of public health concerns about population trends toward overeating and underexercising. Although these concerns focused more on body health and functioning, as opposed to body image ideals, among the cohort of interviewees, the primary and even sole justification for exercising was “the fear of fat” (p. 228). The authors concluded that for the boys and men interviewed, “bodily [image] concern is a stereotypically feminine concern and runs contrary to prevailing ideals of masculinity where body function (rather than aesthetics) is valued” (p. 228). The authors nevertheless found that the desire of these men and boys to look slender, muscular, and attractive coexisted with functional preoccupations (being fit and healthy). At the very least, it appeared that men and boys negotiated issues related to body image in “complex and unpredictable ways” (p. 231).

An earlier review of the literature on boys and body image (Cohane and Pope 2001) did not produce evidence of links between body image and eating disorders but did establish that boys frequently wanted to be bigger. In a much more recent study (Drummond 2012) into the construction of masculinity in young boys (five to seven years of age), muscles and muscularity featured alongside strength, power, dominance, and speed as the most prominent preoccupations and aspirations of the thirty-three Australian schoolboys interviewed. Very little was said about food, diet, or weight that might have suggested negative connotations or difficulties for the boys.

A Qualitative Study of Preteen Boys with Eating Disorders

This article draws on empirical qualitative data collected as part of an Australian Research Council funded study, “A socio-cultural analysis of eating disorders among pre-teenage boys and girls” (see Hartung, Wright, and Halse 2014; Wright, Halse, Levy, et al. 2014). The study included a series of semi-structured interviews conducted in 2012 with twenty-six Australian mothers of children between the ages of five and thirteen. Thirteen of the twenty-six mothers interviewed had a young child diagnosed with an eating disorder. While all child participants were preteens at the time of their diagnosis and initial treatment, one had turned thirteen and one fourteen by the time interviews were conducted. We recruited these families through adolescent eating disorder units at two large public hospitals with specialist ED units in two Australian capital cities. All of the diagnosed children had experienced hospital-based interventions including family therapy, regular weigh-ins, and medication. There were seven girls and six boys with diagnosed eating disorders who participated in the interviews. Research ethics approval was gained through the two hospitals involved and Deakin University. Interview transcripts were analyzed using QSR NVivo 10. The biographies presented in this article were developed through a close reading and rereading of the transcripts from the child and the mother’s interviews, with the intention of capturing how both lived with the diagnosis of an eating disorder. This approach allowed us to understand their experiences and interpretations in the context of the families and to a certain extent their social locations.

By taking this approach, we contribute to the smaller amount of extant literature focusing specifically on preteen boys with eating disorders; specifically we add insights that are only available through qualitative research, a window into lives that may be read in different ways but provokes thought without closing down possibilities of interpretation. In this article, we suggest that these stories disrupt the circulating discourses about the simple nexus between boys, body image, and the media and offer alternative ways of thinking about the issue.

Family Biographies

In earlier work by one of the coauthors of this article (Halse, Honey, and Boughtwood 2008), family biographies were utilized as the main framework for viewing and understanding eating disorders (more specifically anorexia) in the cases presented. Family biography has a particular value for the following discussion because of the way anorexia, among other eating disorders, is recognized as being deeply entangled in “the individual experiences, environments, and sociocultural circumstances of each person’s life” (Halse, Honey, and Boughtwood 2008, 160).

Family biography offers a tool for constituting stories by drawing on interview accounts with different individuals, and this is an important ethical consideration in terms of burden when the interview subject is young and has a health problem. Family biography also provides a structure that highlights complementarities and divergences in the experiences and narratives of different family members, as well as offering a strategy for communicating how and in what ways the presence of an eating disorder affects other family members. The family biographies in this study were constructed using recordings and transcripts of interviews conducted with the six boys with eating disorders and their mothers. Mothers were the only carers interviewed because the assumption was made (and was supported by the study) that the mothers would have primary responsibility for the care of the children, and there was insufficient funding to interview both parents/caregivers. The majority of the mothers in the study with children diagnosed with eating disorders had given up their paid work or changed from full- to part-time work so that they could better care for their children (Wright et al. 2014).

The biographies have been organized in terms of age. Although the number of children and their mothers interviewed does not allow for any generalization on this point, the young boys in the study were more likely to have disordered eating from an early age, while the older boys were more likely to talk about their changes in eating or exercising behavior as related to a desire to shape their bodies in particular ways.

As with any stories, these accounts are always partial and produced in relation to changing material and discursive circumstances (what is important and what people know and believe at the time of the interview). This applies to both the story that is told—that is, a life history or biography tells us about the historical and social circumstances in which the life was lived (Antikainen and Komonen 2003), and the circumstances in which the story is told—how the teller is now positioned (for example, as a mother facing a new crisis with her child or looking to a period of improvement). It also depends on the relationship between the interviewer and the interviewee. The interviews reported in this article were generally conducted in pairs, with the children interviewed, for the most part, by the youngest member of our research team, who could recognize the Internet and media references and was experienced in conducting interviews with children. The interviews with the mothers were conducted by researchers who were older than most of the mothers, were very experienced, and were able to deal with the distress that asking the mothers about their lives with their children often prompted. In most cases, these interviews were lengthy, at least an hour and textually rich, possibly as they presented an opportunity to talk to a sympathetic listener. The children’s interviews, on the other hand, were more likely to be half an hour with much shorter answers. The following biographies have been written by those who interviewed the mothers, using the mother and child interviews together. These stories are shaped by the researchers’ interests and questions and by what the participants remembered at the time of interview and were willing to talk about. Our purpose in writing these biographies is to provide a window into the lives of these children diagnosed with eating disorders and their mothers. We offer the stories as a means of disturbing the certainty of the social, psychological, and medical explanations for eating disorders among preteen boys taken up by the media.

Luis and Lesley

Luis lives with his parents and younger brother in an inner-city middle-class suburb of Sydney. From his mother’s account, Luis’ father works long hours in a high-pressured environment and has high academic expectations of his son. Of all the children (boys and girls) with a diagnosed eating disorder interviewed for this study, twelve-year-old Luis was the only one who identified himself as “anorexic.” He attributes his problems with eating to a comment from a friend that he was “fat” when he was ten years old. His mother agreed with this account but also suggested that the stress of studying for a selective school entry might have had something to do with it. According to Luis, his father suggested that rather than “getting toned” through exercise, he could lose weight by reducing his food intake, and “then I became too really skinny and then anorexia.” Luis was very articulate about his condition. He recalled the way he had been terrorized by food, or the fear of eating, to the point where he “had to stay under my bed and I was so creeped out, I cried and shouted for quite a long time.” Luis described how the “voice” in his head constantly nags him and speaks through him to limit his eating.

I just want to have the freedom, but freedom with my own choice, like not anorexia’s choice my choice. So I choose what I want to have and I choose sensibly but without anyone in the background torturing me.

Discussion

Individually and collectively, the biographies we have constructed around each of the boys and mothers in the context of their families reflect the complexities, subtleties, and even contradictions commonly evidenced in both the biomedical (Madden et al. 2009; Nicholls et al. 2011; Pinhas et al. 2011) and sociological and body image literature (McCabe, Ricciardelli, and Karantzas 2010; Smolak and Stein 2006; Stanford and McCabe 2005; Warren et al. 2010) on eating disorders in children, and preteen boys more specifically. Our analyses of the interview material revealed a number of distinctive, complex, and idiosyncratic scenarios in which each boy and mother has attempted to negotiate the challenges and dangers of the eating disorder, based on the particular ways it was manifesting at the time.

Bronwyn could trace Benjamin’s anxiety back to the time when he was a baby, while Benjamin could recall eating difficulties “pretty much from birth.” Benjamin had, at the time of the interview, recently commenced treatment for an anxiety disorder. The medical literature (American Psychiatric Association 2013a) recognizes anxiety disorder as a typical comorbid condition complicating diagnosis and treatment of eating disorders. Benjamin’s anxiety issues had little to do with his physical size but may have been partially connected to a fear of choking. Typical of other young boys featured in a different study (Drummond 2012), Benjamin had also appropriated aspects of the muscularity discourse that appeared to inform boys’ identification as male/masculine. “Abs” and “muscles” made for “big and strong,” while unhealthy equated with “weak.” These bodily dimensions related more to bodily functioning for sport than good looks. If anything, Benjamin wanted to be able to eat well so that he could recover and maintain his fitness, strength, and sporting successes.

According to Declan’s mother Donna, the comorbidities present in Declan’s condition were at least as significant as his eating disorder. As with Benjamin, anxiety had a major presence for Declan, as did ADHD and in Donna’s view, possibly even autism, although these latter “conditions” had not been medically investigated or substantiated. Donna was convinced that, for her son Declan, “it’s not really a food issue,” and the main work he needed to do was at an emotional level. Here again, Declan’s picture presents as complex and multidimensional, the eating disorder coincident with a number of psychological, emotional, and even environmental disturbances.

With the older boys, there is certainly a stronger link with wanting a different body; for Luis this was prompted by teasing for being fat, and for Kai it was the leanness and muscularity that demonstrated his athleticism. Like other research, which associates boys’ desire for more muscular bodies with their capacity to perform physically (Grogan and Richards 2002; Wright, O’Flynn, and Macdonald 2006), Kai’s disordered eating seemed to be primarily driven by the need to protect his image and reputation as a successful sportsperson, “to have a better body” and to grow up looking “fit and healthy.” His mother attributed his eating disorder to a combined desire to be the “fittest,” “fastest,” and “best.” For Jacob, associations with body image were less apparent, although excesses of overexercising and undereating seemed to be associated with school-based prescriptions for healthy eating. Like Jacob, Kai also used school-based resources about nutrition to inform and limit his food choices. This use of health information accords with literature that points to the ways school education about healthy lifestyles can contribute to children’s narrow equation of health or fitness with eating less and exercising more (Burrows and Wright 2007; Evans, Rich, Davies, and Allwood 2008; Wright and Burrows 2004). Although this does not mean the media has no influence, other factors seemed far more important in both prompting and offering the prescriptions for food selection to maintain these boys’ eating disorders.

Anxiety seems to have played a key role in these boys’ eating disorders. While Luis was the only boy to identify himself as “anorexic,” he simultaneously declared he had OCD and his mother Lesley nominated his “anxiety” and “panic attacks” as being of equal concern to his desire to not be “fat.” These elements of the disorder have a substance and functionality that seem more important than mere body esthetics or a preoccupation with body image. Jacob’s mother Jasmine was also convinced that anxiety was a much more important underlying aspect to Jacob’s eating disorder than any concerns he may have had about body image. She claimed “it’s got nothing to do with him wanting to look thin… [and that] he never looks at himself in the mirror.” Both Jasmine and Ilona suggested that their sons were high-functioning autistic, although they had no formal diagnosis.

A study by Vandenbosch and Eggermont (2013, 299) on the sexualization of adolescent boys suggests that “boys who are in the middle of or just finished transitioning to an adult male body learn to value a muscular, suntanned, spotless, and ultimately handsome appearance as an important, if not ultimate, goal through watching their favorite prime-time television shows and visiting highly sexually arousing websites.” The mean age of the boys in this study was fifteen years. For most of the boys in our study, their interests in the media and the Internet did not extend at this stage to the kinds of prime-time television shows described in this study. Rather, most of the boys in our study were avid computer game players, Minecraft being particularly popular. Minecraft is “a game about breaking and placing blocks” (https://minecraft.net/). The figures in Minecraft are made from constructed of lego blocks and do not project realistic bodies. ABC3 a free-to-air government-sponsored channel specifically designed for “the kids of Australia” and the Disney Channels were popular with the younger boys. The older boys, however, were moving on to action movies and reality shows such as Beauty and the Geek (Jacob) and superhero shows such as the Avengers (Luis) where idealized images of the male body were more likely to be evident. How these impacted on the boys is difficult to determine, however, from their own and their mothers’ comments these did not seem to be what motivated their disordered eating.

Conclusion

Overall, we found very little evidence to support the media-generated popular myth linking boys and eating disorders primarily to body image issues, motivated by aspirations to be more like the male bodies presented in the media and elsewhere in popular culture. Whereas this myth is spoken and communicated through popular media reports on preteen boys, we are concerned about the way this myth “utters its message” (Barthes 1976, 109). This is most problematic when the utterances tend toward the sensational, such as Bain’s (2012) reference to “horrific” increases, “the elephant in the room” and an “increasingly skinny population of young males.” In other instances, even when the language refers less sensationally to “the pressure to stay perfect” or the need to “educate… and breed resilience in young people,” the media myth still works to reduce and simplify a complex and varied set of conditions operating distinctly, and differently, for each boy, mother, and their families. We acknowledge the potential value of popular media attempts to disseminate important public health information to the wider community. However, when this information is mythologized for ease of circulation and perhaps comprehension, the effect is to provide a “perpetual alibi” (Barthes 1976, 123) for much more complex, multidimensional, and nuanced situations that remain concealed or distorted. With evidence pointing to a growing incidence of eating disorders amongst preteen boys (Bayes and Madden 2011; Madden et al. 2009), it is all the more important that the complex and varied nature of this trend is accurately and adequately conveyed through the mainstream media. Countering the media-generated popular myth, and understanding the nature of the problem in more refined and nuanced ways, is crucial for developing an appropriate range of interventions to both treat boys with this serious illness, as well as contributing to a more nuanced understanding for those designing health interventions or health education programs.