ADOLESCENT MEDICINE
Conflicted Adolescent Premarital Intercourse An Antecedent of Mild Anorexia Nervosa? Elizabeth R.
McAnarney, M.D., Robert A. Hoekelman,
AN
cent of unmarried have experienced premarital sexual intercourse by the age of 19.1 The biologic consequences of adolescent intercourse are well known: pregnancy,~ venereal diseases, especially gonorrhea,3 and an increased incidence of cervical carcinoma in women who have had early coitus and who have had several partners The psychologic consequences, if any, have not been defined. This paper considers the possible relationship between the conflicted feelings about premarital sexual intercourse of two late adolescent females and the onset of anorexia nervosa. It is not possible to conclude that one factor in a patient’s experience is solely responsible for specific psychologic symptoms. Since it is generally believed that adolescents who have anorexia nervosa wish to become asexual and usually are amenorrheic, the physician may fail to conduct a complete
F~N estimated 55 per women
From the Division of Biosocial Pediatrics and Adoles-
Medicine, Department of Pediatrics, The University of Rochester School of Medicine, Rochester, New York cent
14642.
Supported by Patient Care Programs—Demonstration Teaching Project in Family Medical and Adolescent Care; Maternal and Child Health Services, BCHS, HEW, Project 148, and Daisy Marquis Jones Foundation. Rochester, New York.
Received for publication January, 1979; February,1979 and accepted March, 1979.
revised
M.D.
sexual
history. This report emphasizes the importance of obtaining complete sexual his-
tories of all late adolescent females who have anorexia nervosa.
Case
Reports
Case 1. ’T’F’ was an attractive 17 ’/4year-old white female from an upper middle class family who was referred to the Adolescent Program for counseling by her pediatrician. She was the youngest of three children and the only daughter of a business executive father and receptionist mother. She was an average student at a village high school and had been accepted to college. One and one-half years before being seen initially, she started having regular sexual intercourse with her steady boyfriend. Subsequently, she had several other sexual partners. Six months prior to being seen, after terminating her relationship with her boyfriend, she began feeling depressed. Five months prior to being seen, she weighed 115 lb, and started a weight reduction diet on which she lost 15 per cent of her body w eight to 98 lb. She didn’t want to gain weight, and didn’t think she was thin. At times she ate excessively, forced vomiting, and also increased her exercise by bicycling. There also a temporal relationship between her symptoms and an argument with her boyfriend. Subsequently, forced vomiting occurred after coitus and she spontaneously suggested that her vomiting and the sexual relationship with her boyfriend might be related. She was amenorrheic intermittently. She was knowledgeable about the biologic consequences of unprotected intercourse, but failed to use contraceptives. She continued her sexual activity, despite weight loss. She felt guilty
340
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about her sexual activity as she was taught by her mother that premarital sexual intercourse was wrong. She felt guilty about her sexual activity, was depressed, had low self-esteem and denied vomiting even though her mother saw her vomit. She was ambivalent about leaving home to attend
college. Physical examination was normal, except that her weight was at the 3rd percentile and her height at the 25th percentile for her age. CBC, urinalysis, SMA-6, and SMA-12
were
normal. She
was
followed
outpatient on a behavioral modification program and gained weight to the 25th percentile for age. Psychological counseling was directed toward her feelings about her eating, independence, sexual behavior and self-esteem. She started college away from home and 3 months later was maintaining her weight. as an
Case 2. MN was an attractive 18-year-old white female from an upper middle class family who was referred to the Adolescent Program with the diagnosis of anorexia nervosa. She was the second of eight children (5 boys and 3 girls) whose father was a business executive and whose mother was a housewife. She was an average student at a suburban high school, and wanted to be a dietician. On a routine physical examination six months prior to being seen, she weighed 117 Ib and wanted to lose weight for her Senior dance. Despite weight loss, she thought she was still too fat and subsequently lost 19 per cent of her body weight to 95 lb over the subsequent four months. Occasionally she binged on ice cream and vomited. She was intermittently amenorrheic, but also used oral contraceptives from 9 months until 2 months prior to being seen. MN initially said she dated the same boyfriend for three years, but denied sexual intercourse. She further volunteered that she was a Roman Catholic and opposed premarital intercourse and abortion. On subsequent history, she reported that she had had a menstrual extraction ten months prior to being seen. She questioned whether the menstrual extraction was an abortion. One month prior to being seen, she terminated her amorous relationship with her boyfriend, but maintained his friendship. She felt guilty about her sexual activity and the menstrual extraction. She was depressed, had low self-esteem, and denied weight loss. She was worried about leaving home to go to college. Physical examination normal, except her weight at the 3rd percentile and her at the 50th percentile for her age. Her pulse was 52/min. CBC, urinalysis, Tine test, SMA-6 and SMA-12 were normal. On her request, MN was
hospitalized on the Adolescent Inpatient Unit, placed on a behavioral modification program and regained weight to the 25th percentile. She left home for college and 4 months later was maintaining her weight. _
Discussion
Although neither patient lost 25 per cent of her original body weight, each fulfills all of Feighner’s other diagnostic criteria and is considered to suffer from a mild form of anorexia nervosa.5 Dally, in fact, states the diagnosis is tenable with a 10 per cent weight loss.6 Other Feighner criteria such as an age of less than 25 years, a desire to lose weight, forced vomit-
ing, bolemia, amenorrhea, overactivity, bradycardia, no known medical or psychiatric illand a distorted attitude toward eating, food and weight are fulfilled. Bruch described an &dquo;atypical anorexia nervosa&dquo; group, which these patients resemble: Those girls are usually older, complain about weight loss, and do not want to stay thin.1 A review of the literature reveals minimal information on the sexual knowledge and behavior, and the incidence of premarital intercourse in adolescents who have anorexia nervosa. Psychoanalytic theory suggests that patients who have anorexia nervosa fear oral impregnation. Dally reported that unmarried anorexia nervosa patients rarely engage in premarital intercourse.6 Rowland wrote that &dquo;another hallmark of the anorexia nervosa patient is his chaotic sexual thoughts and life.&dquo;’ Sexual events have been reported as precipitating the onset of anorexia nervosa in late adolescent girls reacting to conflicted premarital sexual intercourse. In Rowland’s series,8 sexual problems were noted frequently. He reported that for 10 out of 30 patients he followed, anorexia nervosa was thought to be a defense against incestuous desires toward the father. He postulated that if the daughter could become unattractive enough, she could better control her sexual desires. Additionally, 19 of the 30 patients in his series lacked satisfactory heterosexual relationships; 16 expressed fear and guilt regarding masturbation; 9 lacked interest in 6 reported difficulty in having *:ntercoL, rse, and 3 denied all s~=xual nesses,
experience. Of the 94 adults and pediatric anorexia patients studied by Halmi, 29 per cent no positive interest in the opposite sex; 2tper cent dated occasionally; 25 per cent had married and 19 per cent had one child before the onset of their illness; 8 per cent nervosa
341
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had married and 1 per cent had a child after the onset of illness. No comment is made about the numbers of patients who engaged in premarital intercourse, their feelings about their heterosexual relationships, or their conflicts about their sexuality.9 Thus, complete information about the sexual behavior and feelings of anorexia nervosa patients is limited. The changing mores of our society and the peer pressure from the increasing numbers of adolescents engaged in premarital intercourse can lead to stress with which anorexia prone patients cannot cope. Both of the adolescents described here knew that their families did not approve of premarital intercourse but neither was alienated from her family. Thus, both were engaging in sexual behaviors of which they knew their parents disapproved. Both adolescents expressed the distress they felt by this conflict. Several questions are posed by the case histories presented here. If a girl is reared in a home where her parents do not approve of premarital intercourse and she engages in premarital intercourse as an adolescent, is she at risk of developing anorexia nervosa? Once she starts losing weight and becoming more attractive to her male peers, does she become more conflicted about her sexuality and thus become more vulnerable to an eating disorder? What is the relationship between vomiting as a presenting symptom of the anorexia nervosa and the patient’s conflicted sexual activity? In order to document these relationships, we recommend that primary care physicians include a complete sexual history on every patient who has anorexia nervosa. The following questions should be addressed: What does she know about her sexuality; has she engaged in premarital -intercourse; she want to become pregnant; what are her parents’ ex-
pectations about her sexual behavior? If she sexually active, does she enjoy her relationship with her partner? The patients whom we have described have mild anorexia nervosa and responded promptly is
behavioral modification programs which focused on regaining weight to the appropriate percentiles and on discussing conflicts about eating and behavior. Subsequent care included careful monitoring of weights by the primary care physician and continued psychiatric care with the goal of working toward a resolution of the eating disorders and conflicted sexual behavior. to
Acknowledgment Gratitude is extended to Dr. Frank A. Disney for his referral of one of the patients and to Dr. David H. Smith for his assistance in the preparation of this report. Mrs. Anne Donahue and Mrs. Carole Berger assisted in the technical preparation of this paper. °
References 1. Zelnik
M, Kantner JF: Sexual and contraceptive
ex-
petience in young, unmarried women in the United
States, 1976 and 1971. Fam Plan Perspect 9:56, 1977 2.
Furstenberg FF: Unplanned Parenthood: The Social Consequences of Teenage Childbearing. London,
Collier MacMillian, 1976 3. Emans SJH, Goldstein DP: Pediatric and Adolescent Gynecology. Boston, Little, Brown and Company, 1977 4. Martin CE: Marital and coital factors in cervical cancer. Am J Public Health 57:803,1967 5. Feighner JP, Robins E, Guze SB: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiat 26:57, 1972 6. Dally P: Anorexia Nervosa. New York, Grune and Stratton, 1969 7. Bruch H: Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. New York, Basic Books, 1973, pp 236-238 8. Rowland CV: Anorexia and obesity, Int Psychiat Clin 7:3, 1970 9. Halmi KA: Anorexia nervosa: demographic and clinical features in 94 cases. Psychosom Med 36:18, 1974
342
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 7, 2015
Conflicted Adolescent Premarital Intercourse An Antecedent of Mild Anorexia Nervosa? Elizabeth R.
McAnarney, M.D., Robert A. Hoekelman,
AN
cent of unmarried have experienced premarital sexual intercourse by the age of 19.1 The biologic consequences of adolescent intercourse are well known: pregnancy,~ venereal diseases, especially gonorrhea,3 and an increased incidence of cervical carcinoma in women who have had early coitus and who have had several partners The psychologic consequences, if any, have not been defined. This paper considers the possible relationship between the conflicted feelings about premarital sexual intercourse of two late adolescent females and the onset of anorexia nervosa. It is not possible to conclude that one factor in a patient’s experience is solely responsible for specific psychologic symptoms. Since it is generally believed that adolescents who have anorexia nervosa wish to become asexual and usually are amenorrheic, the physician may fail to conduct a complete
F~N estimated 55 per women
From the Division of Biosocial Pediatrics and Adoles-
Medicine, Department of Pediatrics, The University of Rochester School of Medicine, Rochester, New York cent
14642.
Supported by Patient Care Programs—Demonstration Teaching Project in Family Medical and Adolescent Care; Maternal and Child Health Services, BCHS, HEW, Project 148, and Daisy Marquis Jones Foundation. Rochester, New York.
Received for publication January, 1979; February,1979 and accepted March, 1979.
revised
M.D.
sexual
history. This report emphasizes the importance of obtaining complete sexual his-
tories of all late adolescent females who have anorexia nervosa.
Case
Reports
Case 1. ’T’F’ was an attractive 17 ’/4year-old white female from an upper middle class family who was referred to the Adolescent Program for counseling by her pediatrician. She was the youngest of three children and the only daughter of a business executive father and receptionist mother. She was an average student at a village high school and had been accepted to college. One and one-half years before being seen initially, she started having regular sexual intercourse with her steady boyfriend. Subsequently, she had several other sexual partners. Six months prior to being seen, after terminating her relationship with her boyfriend, she began feeling depressed. Five months prior to being seen, she weighed 115 lb, and started a weight reduction diet on which she lost 15 per cent of her body w eight to 98 lb. She didn’t want to gain weight, and didn’t think she was thin. At times she ate excessively, forced vomiting, and also increased her exercise by bicycling. There also a temporal relationship between her symptoms and an argument with her boyfriend. Subsequently, forced vomiting occurred after coitus and she spontaneously suggested that her vomiting and the sexual relationship with her boyfriend might be related. She was amenorrheic intermittently. She was knowledgeable about the biologic consequences of unprotected intercourse, but failed to use contraceptives. She continued her sexual activity, despite weight loss. She felt guilty
340
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 7, 2015
about her sexual activity as she was taught by her mother that premarital sexual intercourse was wrong. She felt guilty about her sexual activity, was depressed, had low self-esteem and denied vomiting even though her mother saw her vomit. She was ambivalent about leaving home to attend
college. Physical examination was normal, except that her weight was at the 3rd percentile and her height at the 25th percentile for her age. CBC, urinalysis, SMA-6, and SMA-12
were
normal. She
was
followed
outpatient on a behavioral modification program and gained weight to the 25th percentile for age. Psychological counseling was directed toward her feelings about her eating, independence, sexual behavior and self-esteem. She started college away from home and 3 months later was maintaining her weight. as an
Case 2. MN was an attractive 18-year-old white female from an upper middle class family who was referred to the Adolescent Program with the diagnosis of anorexia nervosa. She was the second of eight children (5 boys and 3 girls) whose father was a business executive and whose mother was a housewife. She was an average student at a suburban high school, and wanted to be a dietician. On a routine physical examination six months prior to being seen, she weighed 117 Ib and wanted to lose weight for her Senior dance. Despite weight loss, she thought she was still too fat and subsequently lost 19 per cent of her body weight to 95 lb over the subsequent four months. Occasionally she binged on ice cream and vomited. She was intermittently amenorrheic, but also used oral contraceptives from 9 months until 2 months prior to being seen. MN initially said she dated the same boyfriend for three years, but denied sexual intercourse. She further volunteered that she was a Roman Catholic and opposed premarital intercourse and abortion. On subsequent history, she reported that she had had a menstrual extraction ten months prior to being seen. She questioned whether the menstrual extraction was an abortion. One month prior to being seen, she terminated her amorous relationship with her boyfriend, but maintained his friendship. She felt guilty about her sexual activity and the menstrual extraction. She was depressed, had low self-esteem, and denied weight loss. She was worried about leaving home to go to college. Physical examination normal, except her weight at the 3rd percentile and her at the 50th percentile for her age. Her pulse was 52/min. CBC, urinalysis, Tine test, SMA-6 and SMA-12 were normal. On her request, MN was
hospitalized on the Adolescent Inpatient Unit, placed on a behavioral modification program and regained weight to the 25th percentile. She left home for college and 4 months later was maintaining her weight. _
Discussion
Although neither patient lost 25 per cent of her original body weight, each fulfills all of Feighner’s other diagnostic criteria and is considered to suffer from a mild form of anorexia nervosa.5 Dally, in fact, states the diagnosis is tenable with a 10 per cent weight loss.6 Other Feighner criteria such as an age of less than 25 years, a desire to lose weight, forced vomit-
ing, bolemia, amenorrhea, overactivity, bradycardia, no known medical or psychiatric illand a distorted attitude toward eating, food and weight are fulfilled. Bruch described an &dquo;atypical anorexia nervosa&dquo; group, which these patients resemble: Those girls are usually older, complain about weight loss, and do not want to stay thin.1 A review of the literature reveals minimal information on the sexual knowledge and behavior, and the incidence of premarital intercourse in adolescents who have anorexia nervosa. Psychoanalytic theory suggests that patients who have anorexia nervosa fear oral impregnation. Dally reported that unmarried anorexia nervosa patients rarely engage in premarital intercourse.6 Rowland wrote that &dquo;another hallmark of the anorexia nervosa patient is his chaotic sexual thoughts and life.&dquo;’ Sexual events have been reported as precipitating the onset of anorexia nervosa in late adolescent girls reacting to conflicted premarital sexual intercourse. In Rowland’s series,8 sexual problems were noted frequently. He reported that for 10 out of 30 patients he followed, anorexia nervosa was thought to be a defense against incestuous desires toward the father. He postulated that if the daughter could become unattractive enough, she could better control her sexual desires. Additionally, 19 of the 30 patients in his series lacked satisfactory heterosexual relationships; 16 expressed fear and guilt regarding masturbation; 9 lacked interest in 6 reported difficulty in having *:ntercoL, rse, and 3 denied all s~=xual nesses,
experience. Of the 94 adults and pediatric anorexia patients studied by Halmi, 29 per cent no positive interest in the opposite sex; 2tper cent dated occasionally; 25 per cent had married and 19 per cent had one child before the onset of their illness; 8 per cent nervosa
341
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 7, 2015
had married and 1 per cent had a child after the onset of illness. No comment is made about the numbers of patients who engaged in premarital intercourse, their feelings about their heterosexual relationships, or their conflicts about their sexuality.9 Thus, complete information about the sexual behavior and feelings of anorexia nervosa patients is limited. The changing mores of our society and the peer pressure from the increasing numbers of adolescents engaged in premarital intercourse can lead to stress with which anorexia prone patients cannot cope. Both of the adolescents described here knew that their families did not approve of premarital intercourse but neither was alienated from her family. Thus, both were engaging in sexual behaviors of which they knew their parents disapproved. Both adolescents expressed the distress they felt by this conflict. Several questions are posed by the case histories presented here. If a girl is reared in a home where her parents do not approve of premarital intercourse and she engages in premarital intercourse as an adolescent, is she at risk of developing anorexia nervosa? Once she starts losing weight and becoming more attractive to her male peers, does she become more conflicted about her sexuality and thus become more vulnerable to an eating disorder? What is the relationship between vomiting as a presenting symptom of the anorexia nervosa and the patient’s conflicted sexual activity? In order to document these relationships, we recommend that primary care physicians include a complete sexual history on every patient who has anorexia nervosa. The following questions should be addressed: What does she know about her sexuality; has she engaged in premarital -intercourse; she want to become pregnant; what are her parents’ ex-
pectations about her sexual behavior? If she sexually active, does she enjoy her relationship with her partner? The patients whom we have described have mild anorexia nervosa and responded promptly is
behavioral modification programs which focused on regaining weight to the appropriate percentiles and on discussing conflicts about eating and behavior. Subsequent care included careful monitoring of weights by the primary care physician and continued psychiatric care with the goal of working toward a resolution of the eating disorders and conflicted sexual behavior. to
Acknowledgment Gratitude is extended to Dr. Frank A. Disney for his referral of one of the patients and to Dr. David H. Smith for his assistance in the preparation of this report. Mrs. Anne Donahue and Mrs. Carole Berger assisted in the technical preparation of this paper. °
References 1. Zelnik
M, Kantner JF: Sexual and contraceptive
ex-
petience in young, unmarried women in the United
States, 1976 and 1971. Fam Plan Perspect 9:56, 1977 2.
Furstenberg FF: Unplanned Parenthood: The Social Consequences of Teenage Childbearing. London,
Collier MacMillian, 1976 3. Emans SJH, Goldstein DP: Pediatric and Adolescent Gynecology. Boston, Little, Brown and Company, 1977 4. Martin CE: Marital and coital factors in cervical cancer. Am J Public Health 57:803,1967 5. Feighner JP, Robins E, Guze SB: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiat 26:57, 1972 6. Dally P: Anorexia Nervosa. New York, Grune and Stratton, 1969 7. Bruch H: Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. New York, Basic Books, 1973, pp 236-238 8. Rowland CV: Anorexia and obesity, Int Psychiat Clin 7:3, 1970 9. Halmi KA: Anorexia nervosa: demographic and clinical features in 94 cases. Psychosom Med 36:18, 1974
342
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 7, 2015
