Eating Disorders In Males

Statistics

Eating Disorders in Males

It is very hard to know how many men suffer from an eating disorder at any one time. It is also hard to know what proportion of new cases is male. There are many reasons for this. Perhaps we are more sensitive to low weight in women. Women are more likely and from an early age to compare themselves to other women and confess their anxiety about weight and shape. Women talk about food and dieting and are more likely to overtly seek weight loss through dieting, while many men with eating problems hide their difficulties with excessive exercise, or going to the gym. Men are more likely to avoid seeking help, in case they are stigmatised as gay.

A Fairburn and Harrison report in the LANCET, 2002 showed the prevalence of eating disorders in the community as follows:

GENERAL POPULATION MALE INCIDENCE

  • Anorexia nervosa 19 per 100,000
  • Bulimia nervosa 29 per 100,000
  • Binge eating disorder (full criteria) 2%
  • 1 male incidence 1 new case /100k pa
  • 1 male incidence 2 new cases
  • Gender distribution unknown but believed to be as high as 50%

Of note, studies of anorexia and bulimia indicate that in North America there are probably more males with bulimia than females with anorexia.

Males may account for approx 1-5% of patients with anorexia nervosa although prior to puberty the risk increases, and approx 50% of sufferers in children are boys. Males account for 5-10% of patients with Bulimia Nervosa. In actual numbers, bulimia is more common among males than anorexia and will occur in a greater ratio. In actual numbers this means that there are more men with bulimia than there are with anorexia.

Known risk factors for the development of eating disorders in men include dieting, a previous history of obesity, homosexuality and participation in a sport that emphasises thinness. Eating disorders have similar features in males as in females although there are some gender differences in aspects such as age of onset and pre-illness levels of real obesity. Males tend to develop eating disorders later than females with a later age at onset of bulimia, and higher levels of obesity before the illness occurs.

Eating Disorders In General

A great deal of attention has been devoted to the subject of eating disorders and the number of publications on anorexia nervosa and binge eating disorder has grown exponentially during the last half century. Most of these studies relate to women so far. Studies have noted a higher than average incidence of eating disorders amongst specific sub-populations such as adolescent women, college women, or adolescents of higher social and academic status, or in boarding schools. Similarly, there has been a great deal of comment about the correlation between images in the feminine media which impact on female body image and their relevance to the development of eating disorders in women.

In 2009 it was reported that sales of Men’s Health exceed sales of the most popular soft porn publication which has dominated magazine purchases up to now. The growth of a male orientated media in the press and on the internet which is devoted to health and fitness, brings our attention back to male embodiment and how it is experienced. It forces us to ask questions about how this visual media impacts on the body image of male participants and how this affects their health behaviour. Until recently however, and since eating disorders are far less common in males, it has been hard to conduct meaningful research with men since studies are too small to draw reliable conclusions.

Cases of anorexia have been recorded since the 11 th century and the meaning of starvation was attributed to religious yearnings, with starving women being in by far the majority of those described as “fasting saints”. Food disorders continued to be reported only in females with Freud describing cases of both anorexia and bulimia among his patients. The only male to report a problematic relationship with food was Horace Banting in the 19th century, a court official with a serious weight problem who published what might have been the very first diet.

“I could not stoop to tie my shoes, so to speak, nor to attend to the little offices humanity requires without considerable pain and difficulty which only the corpulent can understand, I have been compelled to go downstairs slowly backward to save the jar of increased weight on the knee and ankle joints and have been obliged to puff and blow over every slight exertion, particularly that of going upstairs.”

He then went on to describe his recommended diet which was high in fruit, vegetables and protein, while low in potatoes and alcohol.

In 1959, Albert Stunkard, an obesity specialist in the USA , described the first case of an overeating pattern which he named the Binge Eating Syndrome, in one of his male patients who was struggling to lose weight. This eating disturbance was characterised by dietary chaos, loss of control with eating, cravings for forbidden foods, disinhibited eating, guilty, self deprecating feelings and an intense desire for weight loss. Latterly renamed Binge Eating Disorder, the focus of research attention has focused largely on female sufferers.

Eating Disorders leapt into clinical significance in the late 1970s with the diagnosis of bulimia nervosa for people who binge eat and purge. However it was not until the 1980s that we knew more about demographic patterns, clinical features, psychiatric co-morbidity, and treatment outcomes for all sufferers of eating disorders, identifying their prevalence in males.

Men And Boys Get Eating Disorders Too

Culturally, men are celebrated for what they can achieve and conquer, while women are valued for their appearance. But things are changing and we live in a highly visual culture with a complex and intrusive media that places importance on appearance for all genders and all ages. The message is clear. Being attractive is equivalent to being good. Failure to master the appearance leads to stigmatisation both of appearance and of character.

The question is: do these messages impact on men in the same way as they do in females?

Taking health orientation as a yardstick, it would seem that men are increasingly becoming sensitised to these messages. Gym memberships have exponentially increased. Men now ask for cosmetic surgery. They talk about diets, food plans and supplements among themselves and they are far more likely than they ever have been to go on a diet to control their weight. These changes mask some qualitative differences in the way men and women perceive and respond to their own bodies.

Men do worry about their appearance but:

  • They favour a fit healthy ideal with a v-shaped back rather than a skinny frame. For men there is a social penalty for being underweight.
  • They do not want to look slimmer than other males (as women strive to be thinner than other women).
  • They tend not to view themselves as fat unless they are fatter than most males around them (while women of all weights tend to feel fat as default).
  • They are concerned with their stomach, hair and genital size (while women are sensitive about their hips and thighs).
  • When the average male looks in a mirror they largely perceive an image which is fairly accurate in shape and size, while women see an image which is larger than they really are. In one survey of college students, 13% of males perceived themselves to be overweight compared to 11% who were actually overweight. A similar proportion of the females surveyed were actually overweight but 50% perceived themselves to be overweight.
  • Media images which are iconic for males are strong and muscled, or lean and sporty while for women they are pathologically thin with surgically enhanced breasts.
  • Men do not aspire to standardisation of sizes like the female “size zero” and are thus less exposed to comparison based on absolutes. Women tend to pick their “ideal shape” as much smaller than they are at any weight. With regard to ideal shape, men in studies reliably select the ideal shape that is bigger (more powerful) than they are.
  • So it would seem that although males and females share a culture in which there are strong pressures to attain an appearance which is aesthetically pleasurable and appropriate, there are still some differences in gendered receptivity to these pressures. However, males can and do get eating disorders too.

Triggers For Eating Problems In Males

There are males with Anorexia Nervosa and Orthorexia – which is an addiction to healthy eating. They suffer from Bulimia Nervosa and compulsive overeating too. The presence of an eating disorder in a man can often be traced to a specific trigger:

  • Being bullied or criticised for being overweight
  • Comments from an athletic coach
  • Being in a sport which requires extreme weight control
  • Illness and loss at home
  • A relationship breakdown
  • Not coping with pressures, such as exams
  • A career change
  • Unbearable pressure at work.

Research evidence suggests that males enter an eating disorder pathway through first working out, for example, by going to a gym or running. Then, as the quest for perfection becomes more apparent, they begin restricting food. The surface intention may be to become healthier rather than to lose weight, which is more explicit in females. Because a male may go through a stage of appearing toned, muscular and fit in the course of his disorder, the true pathology of his eating problems may not be apparent until later.

Possible Risk Factors

Dieting

Dieting is known to be a risk factor for the onset of an eating disorder in men as well as women. A researcher called Ancel Keys conducted a controlled dieting experiment with 36 men in the 1940′s. His experiments showed that dieting changes the relationship with food body perceptions with most men feeling an enhanced sense of fatness after their diet.

The Keys studies also showed that dieting resulted in the experience of cravings for foods high in fats and sugars that were not present before the experiment and which were not relieved by normal eating. What was perhaps the most interesting finding in this study is that of the 36 men who started out, most became obsessed with food and weight. 9 of the men became bulimic.

Men in the community at large are less likely than women to go on a weight loss programme by restricting food. By the age of 19, only 1 in 5 males has dieted compared to 8 in 10 females. This protects men to some extent from developing problems with eating. But 9 year old boys have preoccupations with the anxiety about “getting fat” to much the same extent as girls.

Perhaps boys are less concerned to put their concerns into action. Perhaps they are protected by the fact that pubertal boys gain height and muscle while pubertal girls gain height and fat. Almost certainly they are protected by the fact that male perceptions of the body differ from those of females. Also, self esteem in males is less entwined with ideas about the significance of what they weigh- even despite the society in which we live.

The Media

The media, as already described, emphasises physical fitness and bodybuilding for males. A survey of the 10 magazines most commonly read by young people revealed that men’s magazines contained more than 10 times fewer advertisements and articles promoting weight loss as women’s’ magazines, (Andersen and DiDomenica 1992). These investigators argue that the 10-fold difference in this gender-related reinforcement of dieting behaviour is more relevant than any biological parameter to the difference in eating disorder prevalence in males and females. But this ratio of health to weight loss exposure has changed radically since then.

Attractive is Good: There is also a shift in cultural norms which are now portraying a slim lean and highly toned body as the aesthetic male ideal. Is this leading to a new male quest of striving to achieve these aesthetic ideals, not only for expected health benefits, but also for what the ideals symbolise – control, self discipline, competence and sexual desirability? We now associate overwhelmingly positive “masculine” personality traits to slim, toned males just in the same way as we talk approvingly of women who achieve the slim ideal; perceiving these icons of physical perfection as more altruistic and noble, with high moral values.

Sports

Athletes who participate in sports that emphasise leanness, or that match participants by weight (boxing, wrestling, rowing) and competitive body builders, are at risk for engaging in severe dieting and fluid restriction. In small studies in which dietary restraint and attitudes towards eating were surveyed, high performance male athletes, including distance runners, have shown disordered eating, poor attitudes toward body image and dieting behaviours that are comparable to those of females with eating disorders.
Although we are not sure about the link between athletic pursuits and the development of eating disorders in males, some researchers believe that male athletes may be especially vulnerable to developing full-fledged eating disorders.
Jockeys however are thought to be a particularly vulnerable group and many indulge in very serious weight control practices. An article about weight control practices in jockeys is on the NCFED website.

Gender Orientation

There is a direct connection between homosexuality and eating disorder in males but not in females. This does not mean that all males with eating disorders are gay. Only 20% of males with eating disorder are thought to be gay. However the expectation that a male will be regarded by a health professional as gay stops many men from getting the help they need.

The homosexual male subculture places greater emphasis on body appearance and shape, and this focus on physical appearance might heighten males’ vulnerability to body dissatisfaction and disordered eating. In a study of 71 homosexual and 71 heterosexual men in a university community (Silberstein et al). and in a study including 59 homosexual and 62 heterosexual male college students (Siever), the homosexual men had more body dissatisfaction on psychometric tests, and they considered appearance more central to their sense of self than did the heterosexual males, in both studies.

Yager and associates reported that 48 homosexual male college students had higher prevalence of bulimic behaviours and fear of weight gain than a heterosexual male comparison group.

Herzog et al. have reported that significantly more of the 27 male patients evaluated on an inpatient eating disorders unit reported sexual isolation, inactivity and conflicted homosexuality than a comparison group of eating disordered females on the same unit.

There is persuasive evidence that male bulimics have a higher prevalence of homosexuality than their female counterparts and that homosexuality acts as a risk factor for bulimia in males, according to Carlat and Carnago 1991. These researchers also claim that bulimic men have a lowered libido, while females with bulimia appear to show no parallel decrease in sexual interest.

Don’t jump to conclusions . Bear in mind that every individual is different. Yes, there is a higher incidence of bulimia and other eating disorders in homosexual males than in heterosexual males. But again, most males with eating disorders are not gay.

History Of Obesity

Frank obesity is a risk factor for disturbed eating in males. This differs in women, where the risk is highest among women who think that they are fat. Several small studies have shown that males with eating disorder tend to have had more serious weight problems before the eating disorder set in. Edwin and Anderson ‘s report on 76 male inpatients and outpatients referred to an eating disorder treatment service, found that the males tended to have higher lifetime maximum BMI levels than females. Mean maximum weight was 130% of ideal for males and 120% for females.

These findings are intriguing because we have already noted that males may have some protection from eating disorders because they are less likely to diet, and have better body image overall. However males who are actually obese or are in an environment which emphasises thinness, may experience negative comments from other people and a heightened pressure to diet. Appearance concerns in boys can set in at a very young age if they are ridiculed for their size. Fat male children are as likely to experience fat teasing as fat female children which can have an impact on their self esteem. Boys who are bullied for their weight are at risk of becoming aggressive, tending to be critical and deprecatory of other children. So, being fat can expose the men to the same environmental pressures experienced by females.

Personality

Males with eating disorders show disorder-specific personality characteristics exactly the same as in females. There are high levels of perfectionism, harm avoidant character styles and relationship difficulties. Anorexic males, like females, have problems with flexibility, obsessional features – which may be a consequence of emaciation – a high drive for simplicity and maturity fears. They are likely to have underlying anxiety and obsessive compulsive characteristics. Bulimic males, like females, tend to be novelty seekers, impulsive with a possible history of past or current substance abuse.

Since most men come to research attention after contracting their eating disorder it is not possible to know to what extent these symptoms-such as obsessionality – are starvation induced.

History of Trauma

Research is less clear about the relationship between a history of abuse, neglect or trauma in males although there are associations with women who develop problems with food. Therapists must be sensitive about the possibility of a history of abuse or loss, which has not been addressed in part because of male imperatives to just “get on with things” together with a reluctance to disclose their feelings.

Alcohol Abuse

Studies of addiction have identified both males and females in treatment for drug and alcohol abuse who also have overt eating problems with food. These problems may be evident at presentation or they may emerge in the course of treatment. This has led to a great deal of research to identify the current and sequential link between addiction and eating disorders in both genders and to explain the evident link.

In 2002, Gadalla and Piran conducted a major study in the community among 37,000 adult males and females randomly selected. The purpose of the research was to identify the incidence of, and relationship between all substance use and eating pathology. This identified interesting patterns that distinguished males and females. There was a very strong link between mood altering drugs (such as cocaine, hallucinogens, crack and heroin) and eating disorders in females, but not in males.

This and other studies show that bulimia is over represented in alcoholics in both sexes

Various studies have looked at the sequential relationship between eating disorders and addictive behaviour to see if one leads to the other or predicts the other. The evidence suggests that, in males as well as females, the strongest relationship between the two disorders is that eating disorders – especially bulimia, may lead to later substance abuse. However, in some males (and females), alcohol dependency will increase the risk of an eating disorder setting in.

Many studies do not differentiate between type of eating disorder, gender and type of compulsive or dependent behaviour. Thus we cannot interpret the data fully but we cannot ignore it either. It is possible that men who with eating problems might turn to alcohol to block the distress of their bulimic behaviour, or may use alcohol to try to deaden their appetite.

Anorexia Nervosa

Recent studies that focused on the course of eating disorders in males and the incidence of co-morbid psychiatric diagnoses, demonstrate remarkable similarities between males and females with eating disorders.

According to criteria in the American Psychiatric Association’s Diagnostic and Statistical manual, (IV), individuals with anorexia nervosa refuse to maintain a minimally normal body weight for age and height, (less than 85% expected weight); they are intensely fearful of gaining weight or becoming fat, and exhibit a significant disturbance in the perception of body weight or size. Additionally, for women, the diagnosis insists on loss of periods for at least 3 consecutive cycles. This objective criterion – amenorrhea, is lacking in males with anorexia. This makes it harder to recognize anorexia in males. However most studies report that males and females with anorexia behave and think in very much the same way.

Males With Anorexia Are More Likely To Purge & Exercise Even More

Patients with anorexia nervosa are sub-classified in the DSM-1V into either restricting or binge eating/purging types. Restrictors lose weight mainly by dieting and/or exercise. Binge-purgers may have episodes of binge eating and/or may regularly self-induce vomiting and abuse diuretics, laxatives or enemas. Various studies of males with anorexia and matched female groups, concur in finding that binge eating and vomiting occur commonly in approximately 50% of the males with anorexia compared to 33% of females with anorexia. Excessive exercising was found to be more frequent and laxative abuse less frequent in the male group than in the female group, which is in agreement with other studies.

Age Of Onset

Studies on age of onset in males disagree, with some saying that men get anorexia later than women. Female anorexia has peak onset in adolescent years, with the vast majority developing the disorder between the ages of 13 and 20. A review article by Sterling and Segal, however, cites a mean age of onset of 13.7 years of age for males versus 17 or 18 years for females.

Puberty occurs, on average 1 to 2 years later in males than in females. This is of interest because puberty in girls heralds the period of highest risk for anorexia. However puberty may have very different meanings for girls and boys in terms of its relationship to body image. Subcutaneous fat deposition in the breasts, buttocks, hips and other areas that contribute to the mature female contour is a dramatic feature of the pubertal process in females. Males do not experience body fat gain in puberty, in fact the reverse, males tend to lose fat and gain muscle in adolescence. Studies have noted major differences between males and females in their response to early maturation. Girls who begin puberty early, experience a loss of self-esteem and a higher incidence of self abuse. Conversely, males who mature early gain self worth, social status and emotional strength.

Physiology Of Males With Anorexia

The physical outcomes of starvation in men include stunting of growth and decrease in plasma gonadotrophins, which in turn lead to loss of sexual drive. Men get osteoporosis too. When males with anorexia regain their weight, the increase in plasma leuteinising factor boosts hormone and testosterone levels, kindling physical and emotional puberty. Weight gain in growing females changes the physiology in similar ways and at similar thresholds of pre-illness weight.

Psychological Explanations

Some psychotherapists believe that anorexia in men is atypical – a flight from their feminine side which has not been adequately integrated into the psyche during the course of their development – and which is represented by their body fat. The male body, parodied into an ultra lean frame, could be the last refuge for men who are trying to hang on to certain masculine distinctions in a world where female working and sexual roles can undermine male confidence. This is only one of a number of “control” explanations of the illness in males. Men with anorexia, as already described, have similar problems with self regard and emotional resilience as do women.

Bulimia Nervosa In Males

Bulimia nervosa is a disorder of binge eating and inappropriate compensatory methods to prevent weight gain. The behaviour in bulimia may take the form of vomiting, laxative, diuretic abuse or excessive exercise. Bulimics tend to be unduly influenced by their body weight and shape and have strange ideas of how much it is appropriate to eat.

Age Of Onset

The mean age of onset for bulimia is between 18 and 26 for males, compared to age16-18 in females. However, larger studies are needed to confirm that men tend to get bulimia at an older age than women.

Psychiatric Co-Morbidity For Bulimia, Males vs. Females

Males with bulimia have a high prevalence of depression, anxiety disorder substance abuse and personality disorder; particularly cluster B personality disorders – i.e. borderline, histrionic, narcissistic, and anti-social personality disorders. This is exactly the same as in females.

Binge Eating Disorder In Males

Binge Eating Disorder exists when there are recurrent episodes of binge eating without compensatory behaviours, except for dieting. Binge eating is defined as eating within a discrete period of time (e.g. within a 2 hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances. People who binge feel out of control around food some of the time both before and during an eating event. They usually have strong cravings for “forbidden food” and they feel ashamed and miserable about their behaviour. Over-evaluation of shape and weight are part of the disorder.

In the absence of good quality research we estimate that binge eating among males could be as common as it is among women in the community at large. People who binge but do not purge usually struggle with their weight, and there are certainly as many overweight males as there are females. We estimate that up to half of all persons who are obese, male or female, satisfy the criteria for binge eating disorder or its subclinical variant which is loosely and aptly defined as “compulsive eating”.

Males seem to be less bothered about binge eating. This may explain why they are less inclined to purge and less inclined to address it by, for example, heading off to slimming clubs or going to the GP to demand a diet pill.
Males who do not have anorexia or bulimia also appear to have lower perceptual sensitivity toward their eating habits and are less likely to describe an episode of overeating as being a “binge”. They are also less scared of the effects of a high calorie meal.

Muscle Dysmorphia In Males

The term “Adonis Complex” has been coined to describe the situation of men who develop body image disturbance and whose apparent motivation is to achieve the cultural “ideal shape for males.” To become, in other words, the 21 st century Adonis, loved and desired by all. However, the obsessive behaviours and abuse of chemicals, hormones and steroids in pursuance of this goal may cripple both physical and emotional health. The disorder goes largely unrecognised and untreated.

Muscle Dysmorphia is, like anorexia, a perceptual disturbance of the body which is, in this case, considered too thin, too puny and too flabby. The consequence of this perceptual disturbance is the adoption of harmful weight and shape control practices. These usually involve a change of diet which is also harmful, such as purging if the man eats fat. Thus the condition may morph from a body dysmorphic disorder into an eating disorder.

Personality

Men with Muscle Dysmorphia are similar to men with anorexia. They are likely to compare themselves constantly and critically to men with more muscle in the same way as the male anorexic compares himself to males who are leaner. They are perfectionist, obsessive, anxious and usually have low self esteem.

Behaviour

Practices which attempt to “compensate” for the perceptual disturbance of being too puny include muscle building sport, performed beyond the point which is good for health and wellbeing. The sufferer is likely to seek supplements which boost muscle size and seek illegal anabolic steroids or other hormones which will help them to lose fat and bulk up muscle.

Muscle dysmorphics will become obsessed about the quality of food and its powers to make them “fat”. They may cut out major food groups such as fat and overdose on protein. Dietary chaos and nutritional deficiencies often lead to reactive binge eating and it is not unusual for sufferers to purge so that they will not gain fat.

The similarities between male anorexia and the Adonis complex is that they may be opposing expressions of the same condition. In both, there is denial of a problem and a relentless pursuit of perfection. Even if men admit to either of these problems, there is a double taboo. Reluctance to talk about personal difficulties and a self esteem penalty for even having feelings about the appearance of the body. By definition, the eating disorders and the Adonis complex are something that men don’t want to talk about.

Treating Eating Disorders In Males

Current theory suggests that males respond to the same treatment for eating disorders as females. Therapy for eating disorder must be holistic, embracing physical, psychological and interpersonal interventions.

There are no good quality studies which would help us to identify extra aspects of treatment which would be helpful to men. They may, for example, prefer a male therapist while women prefer females by and large who they feel are more sympathetic to their concerns.

Men also benefit from social support, although one major problem is that eating disorder settings and services usually have a very high ratio of female patients. Many men are reluctant to join groups which are largely composed of women who may be talking about Kate Moss rather than a male athlete.

Even so, a group can be good in helping a man to confront the self esteem issues that may have led him into his problem. So it is helpful to persuade a male sufferer to give it a go.

Antidepressants are of variable value in treating bulimia, however, there are no published studies on whether they are particularly useful for males.

CONCLUSION

Although anorexia and bulimia remain predominantly female illnesses, these disorders are sufficiently common so that even if only 5% of sufferers are male, hundreds of thousands of young men are affected, making it an important health problem for males. This is compounded by a tendency for eating disorders in males to go unrecognised or undiagnosed, due to reluctance among males to seek treatment for these stereotypically female conditions. This may now be changing due to increased public information and awareness.

More work needs to be done to identify treatment approaches which are especially helpful to males, as well as prevention strategies which will help males as well as females maintain a balanced relationship with food.

ARE YOU A MALE WITH AN EATING DISORDER?

  • Does eating play great significance in your life?
  • Is someone else concerned about your weight even though you think you are OK?
  • Do you ever make yourself sick to stop yourself from putting on weight?
  • Have you lost more than one stone in the last 3 months?
  • Do you feel that at times you are not in control of your eating?
  • Do you feel unbearably anxious if you don’t exercise?

If you have answered YES to two or more of these questions you may have an eating disorder. The NCFED has male as well as female therapists to talk to, and provide support.

Books & References

Books

Self-Help is one useful treatment approach and sufferers as well as therapists will benefit from learning more about eating disorders in men. The NCFED recommends two such books

  • The Invisible Man:A Self-Help Guide for Men With Eating Disorders, Compulsive Exercise and Bigorexia. John F. Morgan, Yorkshire Eating Disorders Service. Routledge Press
  • Boys Get Eating Disorders Too ; Coping with Male Eating Disorders Jenny Langley. Sage Books

References

  • Arnold E Andersen & Lisa Di Domenico 1992. Diet vs Shape content of popular male and female magazines: A dose response relationship to the incidence of eating disorders? International Journal of Eating Disorders
  • DJ Carlat , CA Camargo Jr, DB Herzog 1997. Characteristics of male patients with eating disorders American Journal of Psychiatry, Am Psychiatric Assoc.
  • DB Herzog, DK Norman, C Gordon, M Pepose 1984. Sexual conflict and eating disorders in men. American Journal of Psychiatry, Am Psychiatric Assoc
  • RA Leit, JJ Gray, HG Pope Jr. 2002 – The media’s representation of the ideal male body: A cause for muscle dysmorphia? International Journal of Eating Disorders . Volume 31 Issue 3, Pages 334 – 338.