Body Dysmorphia in Gay Men

October 11, 2016 marked the 28th anniversary of National Coming Out Day. In addition to celebrating coming out as lesbian, gay, bisexual, transgender, queer (LGBTQ) or as an ally, this annual Human Rights Campaign event offers clinicians an opportunity to explore topics related to effective treatment for patients in the LGBTQ community.

Below, Zach Rawlings, MA, LPC, PsyD.Cand, explores the prevalence of Body Dysmorphic Disorder (BDD) in gay males. A member of Eating Recovery Center’s Clinical Assessment team, he provides meaningful context for this trend as well as clinical guidance for professionals working with gay patients

A notable and pervasive issue with a more physical focus has started to plague the gay male community

Body Dysmorphic Disorder (BDD) is a psychological diagnosis that refers to one’s preoccupation with a perceived defect or flaw with his or her physical appearance.

This can lead to repetitive behaviors like mirror-checking, excessive exercise and reassurance seeking.

Gay men have become the new face for BDD.

It’s no secret that gay men tend to be obsessed with their bodies. What other reason could explain the obsession with working out and the endless shirtless selfies on Instagram?

Gay men even categorize each other based on physical appearance by using words like twink, otter or bear. And despite this diverse classification based on physical characteristics, there is an ideal that most gay men try to achieve, and this ideal looks a lot like Zac Efron. Efron’s straight co-star, Seth Rogen, recently commented that he “looked like something a gay guy designed in a laboratory.”

There are many theories that attempt to explain gay men’s complicated relationship with their bodies, but perhaps the most viable is that of Alan Downs. In his book, The Velvet Rage, he discusses the role that shame-based trauma plays in how gay men construct their sense of self.

Being raised in a milieu where you’re told you don’t measure up to the masculine ideal sets most young gay boys up to feel they need to overcompensate to hold onto other people’s affections. Many gay men have attempted to hold onto those affections through efforts to perfect their bodies.

When someone has a history of rejection (name-calling on the playground, getting crammed into lockers, ridicule for feminine interests, etc.) he might work tirelessly to achieve acceptance throughout his life—after all, rejection creates a thirst for acceptance.

While attempting to change or suppress one’s mannerisms, personality and interests are difficult—if not impossible—to do, changing one’s body is more achievable. In the quest to attain acceptance, the gay man’s best strategy is attaining the masculine body ideal, complete with chiseled arms, bulging pecs and washboard abs.

By working out tirelessly and reaping the sexual attention that comes from such intense workouts, the gay man can temporarily assuage the root anxiety and fear he carries about being rejected. Working out is something he can control—heavier sets, more protein shakes, more crunches. In turn, he can have his choice of sexual partners and glean (temporary) male acceptance.

Although a creative coping mechanism, excessive focus on achieving the ideal body does nothing to address the root problems driving the maladaptive behaviors and negative body image: self-hatred, shame and unresolved trauma.

When you feel badly about yourself, gym time and caloric restriction will not heal that wound.

In an environment wherein physical attractiveness has become the primary value, there is fierce competition to attract partners and physical attractiveness becomes the main comparison point. The same perfectionistic, high achieving temperament that helps a gay man achieve weight loss and physique goals also drives eating disordered behaviors and BDD.

Struggles abound for gay men that don’t fit the masculine ideal, including higher weight men and those that suffer from binge eating disorder and/or compulsive overeating. In his article “It Gets Better, Unless You’re Fat,” Buzzfeed writer Louis Peitzman talks openly about the pain of being an overweight gay man who struggles to measure up to the gay physical ideal:

“The truth is, the gay community isn’t interested in embracing overweight people because we’re a blemish on the image of perfection. And much in the same way progressives as a whole can get away with ignoring anti-fat bigotry, gay men never bother examining the way they treat their overweight brothers. Ignore us or relegate us to the butt of hackneyed jokes: We just don’t matter. It doesn’t get better for us.”

Gay men who buy into this drive for the perfect body to hide their insecurities are actually hurting themselves and others who don’t measure up.

Chiseling the perfect body is a great distraction from the underlying feeling of not being good enough.

For many gay men, it short-circuits the ability to address the root problem and to process emotion deeply and authentically. For a subset of others, specifically those genetically predisposed to eating disorders, the tireless pursuit of the ideal gay physique may evolve in to a life-disrupting (and at times life-threatening) eating disorder

For clinicians working with gay patients, it’s important to consider this meaningful psychosexual context when exploring eating, exercise and body image concerns. Coming from a sexual minority, these patients have unique, often painful developmental histories marked by trauma, fear of being ostracized or rejected, and/or trauma associated with these fears having been realized. They internalize these feelings and take it out on their bodies, attempting to wield control through weight loss and/or building up muscle mass (hence the pervasiveness of BDD in the gay community).

Consider the following clinical best practices:

1. Conduct a thorough assessment — In addition to a comprehensive eating disorder assessment, include an age-appropriate assessment of psychosexual development. Consider exploration of the following topics related to sexuality:

• Family non-acceptance
• Peer harassment and bullying
• Community bias and hostility
• Unequal social status
• Trauma
• Internalized negative attitudes (ie. observations related to social status, identification with stigmatized group or self-loathing, conflict between wishes for authentic identity and belonging)
• The developmentally significant struggle of “coming out” versus “staying in the closet” (denial or hiding may be adaptive, family reactions are diverse ranging from hatred for gender variance to grief over lost expectations)
• Substance abuse (elevated use, earlier onset and faster progression among certain LGBT subgroups; bisexual males and lesbians may be at higher risk for substance abuse; drugs/alcohol often used to achieve feeling of belonging or relieve painful effects of trauma, rejection, self-hatred, etc.)

2. Be wary of attempts to justify BDD and/or explain away the body dysmorphia in the gay community (like this one) — Body obsession isn’t about being physically healthy; it’s about overcompensating for an internalized fear of rejection and self-hatred due to a childhood and adolescence filled with shaming.

Make no mistake about what the true purpose is—gay men pay for gym memberships and personal trainers in droves to offset the nagging shame gremlins that lurk in their psyches. Physical health has very little—if anything—to do with it. Rationalizing exemplifies the hedged emotional processing that most gay men partake in.

3. Emphasize emotional processing. — Carrying internalized shame squelches emotional processing because it tells us that we can’t handle what is actually behind the curtain covering the darkest corners of our minds. Shame tells us that a perfect body to plaster all over Instagram is the only thing that can keep people interested in us. Shame tells us that with excessive workouts, calorie counting and emotional avoidance, we can achieve happiness and contentment. But shame is what keeps the high rates of eating disorders, body dysmorphia and depression alive and well in the gay community, and this shame is telling us lies.

Clinicians can thoughtfully and compassionately explore these lies gay patients have accepted in order to avoid looking at their real vulnerabilities.

4. Be prepared to consult and act as a liaison — with other health care providers, schools and relevant community in an effort to advocate for the unique needs of sexual and gender minority patients and their families. Targeted resources are increasingly abundant; however shame, fear and hurt can keep even the most well-meaning and motivated people from getting the help they need.