Many of us would probably characterize a person with an eating disorder as being a once-healthy looking person who has subsequently starved themselves to a near-skeletal weight. Particularly with adolescent girls or young females, eating disorders often play out this way in the form of an eventual diagnosis of anorexia or bulimia.
However, body dysmorphic disorder differs from this traditional idea of an eating disorder in that a person sees their body, or a feature of their body, differently than it really is. People suffering from BDD tend to intensely focus on appearance or body image to the point of obsessing about a perceived flaw in their appearance, such as a fixation on your nose, complexion, skin appearance, hair or muscle size. Though BDD may seem like a form of intense vanity, it is actually a mental health disorder. Likewise, we are also seeing an increasing trend in boys and young men who are also struggling with BDD, particularly those with a specific condition known as bigorexia.
Bigorexia is not an eating disorder, but a form of muscle dysmorphia, nicknamed ‘reverse anorexia’ because those who have it want their bodies, or parts of their bodies, to be larger and more muscular. Bigorexia is the belief that one’s body or muscles are underdeveloped or too small. Boys and young men with bigorexia may go to extreme lengths to bulk up, often engaging in dangerous behaviors such as steroid use, drastic dietary measures, and working out obsessively in order to get ‘ripped.’
According to Boston Children’s Hospital findings, about 60% of young boys in the United States say they’ve changed their diet to become more muscular. Though this isn’t necessarily an indication of muscle dysmorphia, it is something we need to understand better. We have long identified the pressure for physical perfection as a factor in anorexia and bulimia in women and girls. Boys are also receiving social messages about the ‘perfect’ male body. Just consider the rippling muscles on Marvel action heroes, anime and video game characters — even Halloween costumes for boys include padded and painted-on muscles. A growing number of young people coming in to Marblehead Counseling Center are struggling with the anxiety and depression that develops from the constant comparison to others on social media.
Muscle dysmorphia can affect people of any age or sex, but is especially prevalent in teen and young adult males ages 15-32. One issue for parents and health care professionals is that unlike anorexia, bigorexia comes in all shapes and sizes, which subsequently can make it hard to recognize in others. The 2024 Study of Boys and Men, which analyzed data from 1500 participants in the United States and Canada, suggests that muscle dysmorphia may be more prevalent than previously thought — affecting approximately 3% of respondents, spread consistently across socio-demographic, age and gender lines. The authors of this study suggest that parents and health-care providers need to do a better job looking for signs that our boys are struggling with body image.
Key signs
The common assumption for many has been that BDD is a ‘girl’s issue,’ which means we often miss the clues that our sons are in distress. A perfectly healthy looking teenage boy might seem like he is working out more than usual, when in fact, he is under extreme stress about his appearance. One of the most important signs to watch for is the level of intensity with which boys approach working out and dieting.
Most people have been on a diet at some point in their lives. People with bigorexia are obsessed with what they eat for a persistently long period of time — sometimes weeks and months of severe restrictions on food intake and adherence to rigid eating schedules. Some boys try extreme dieting such as the ‘bulk and cut’ regimen of rapid weight gain followed by severe caloric restriction. ‘Hitting the gym’ may become an obsession, where hours that used to be devoted to other activities are now spent on multiple hours of weight lifting and working out.
Boys with BDD might start adding protein powders and supplements to their regular diet — often unregulated — hoping to bulk up. These may include stimulants or steroids to add muscles. Surveys have shown up to seven percent of high school students in the United States have used steroids, but experts believe the true number may be even higher.
These additives along with extreme dieting put users at risk of possible stroke, high blood pressure, liver and/or kidney disease and even sterility. Boys who begin using anabolic steroids as teens show increased impulsivity and decreased attention spans as compared to men who began using steroids in their adult years.
Changes in behavior and mood can also be unusually intense. Malnourishment alone can lead to depression and suicidal ideation. Being unable to meet such unrealistic body ideals may also cause a sense of failure and unworthiness. The concern that they are already not measuring up is exacerbated by the body’s discomfort and an inability to achieve impossible goals. Moreover, steroid use in young people can cause a host of health problems, including cognitive issues that occur in school and at home.
Root causes
It cannot be overemphasized that body dysmorphia is not about vanity. It is a mental health disorder where many factors may contribute to its onset. In one study, 94% of youth with BDD described experiencing social difficulties resulting from embarrassment and shame related to their appearance. Our society’s underlying messages about power and worth prompt many boys to worry about how to measure up.
According to the National Alliance for Eating Disorders, other risk factors include being in the 15-32 age range, having a family member with BDD, experiencing childhood trauma, being bullied as a child, encountering frequent exposure to social media that features messaging about ‘ideal’ body shapes/sizes and engaging in bodybuilding, weightlifting and other types of athletic activities. Boys and young men who might be susceptible to BDD often have another mental health condition, such as obsessive compulsive disorder, another eating disorder, depression and/or low self-esteem. A preoccupation with perceived flaws and the subsequent shame and anxiety related to these ‘flaws’ are also cause for concern.
Healthy steps
Not all boys or young men working out or paying better attention to their diets are at risk of having BDD. Teens often go through phases, and as they begin to define themselves in the world, they can be extremely self obsessed. Parents can be proactive with their boys around body image in a number of important ways.
Keep an eye on the persistence, rigidity and intensity of workouts and dieting. Does it feel like an obsession over a long period of time?
Try and set up a space where healthy eating and exercise habits are part of your family routine. Have dinner together, take a walk or hit the gym as a family.
Pay attention to how you speak about your own perceived imperfections. If you’re obsessing over your own flaws and speaking negatively about yourself, your child will likewise pick up on these attitudes.
Don’t allow kids to take supplements or steroids without a medical professional’s guidance and direction.
Listen to his concerns — it’s tough to feel you don’t measure up. Your patience, willingness to hear him out and loving concern are all key components for your child’s healthy emotional development, trust and long-term well-being.
Bigorexia and other types of body dysmorphia disorders are serious mental health issues. Because the physical signs are not as obvious with bigorexia as they are with other eating disorders, you might be unsure whether your child is at risk. A mental health counselor can help answer some of your concerns.
Gregg Mulford has been a social worker for 35 years, the last three of which have been counseling individuals, families and couples at Marblehead Counseling Center. He is a generalist who works with all populations, on a wide range of issues, including anxiety, depression, substance use, OCD, agoraphobia and bipolar disorder.
