For decades, mental health professionals, researchers and the popular press have assumed body image problems and eating disorders were women's illnesses. Because of their association with women, many men have been hesitant to admit that they struggle with these issues for fear that they would be considered “less manly” or “effeminate.” Additionally, it has just been in the past twenty years or so that men's bodies have begun to be objectified in the way that women's bodies have been for decades.

Gay culture and media take the obsession with men's bodies even further, as evidenced by a visit to a gay pride parade, by glancing through a gay publication, or by stopping by a gay club on any weekend evening. Because of this, many people have suggested that gay men are more at risk for body image disorders than straight men. Gay men, on average, probably suffer more teasing about their bodies when growing up, they may be more insecure about masculine gender identity, and body appearance is experienced as more important in the gay culture. Additionally, gay men scrutinize (and are scrutinized by) other gay men who may be potential sexual partners. These men often compare their body with that of their partner, judging sexual attractiveness by who has less body fat, who has more musculature or who has the largest penis.

The HIV/AIDS epidemic has particularly heightened gay men's sensitivity and awareness about body appearance. The frightening image of AIDS-related wasting syndrome (severe loss of weight and muscle over time) and lipodystrophy (redistribution of fat within the body) has left an indelible mark on the gay consciousness. Now, gay men routinely comment that thinness is ugly because it speaks of sickness and death. Fat is bad; muscles equal health. Exercise promotes fitness — therefore the more you exercise the fitter you will be. Muscularity enhances the look of the male body — therefore, the bigger your muscles the more attractive you become. Goals which may in themselves be harmless or even beneficial can take such a hold of the individual that they dominate, and even to some extent define, the personality.

Body image — like many other concepts in mental health — can be measured on a continuum: healthy body image on one end, body image “problems” somewhere in the middle, and pathologic body image “disorders” on the far end. Body issues that first manifest as a problem for some gay men often develop into a disorder if not addressed. Unfortunately, many gay men do not openly talk about their body issues, thereby “concealing” their concerns from mental health professionals. It is only when the problem causes major life consequences that a body image disorder is admitted by many men.

Manifestations in Gay Men

Many gay men have healthy body images and eat/exercise in a way that promotes the maintenance of positive self-esteem. It is not suggested that everyone who diets or engages in the pursuit of fitness or physical development will fall victim to body image problems, or — in its extreme — body image disorders. In most cases, a sense of proportion and the need to get on with the ordinary tasks of living prevent their quest for the physical ideal from escaping rational control. In any of its manifestations, however, physical perfection can become so powerful an influence on certain individuals that it assumes obsessive proportions and turns into an addiction. The following are increasingly common disorders seen in patients at Pride Institute as well as in the clinics/offices of mental health professionals serving gay men:

Eating Disorders:

Several million men (a disproportionate percentage of them gay) have suffered from compulsive binge eating or from anorexia nervosa and bulimia. Countless others with milder forms of eating disorders diet and worry about being fat even when they actually look just fine. Many experience uncontrolled cycles of weight gain and weight loss or have dietary patterns that eventually cause physical problems. Although related to “eating”, the “eating disorder” can be somewhat misleading because these conditions in gay men usually stem from an underlying body image problem. The eating disorder is actually a symptom of the primary body image disorder.

Weight-Lifting and Exercise Compulsions: Gay men's quest for a more muscular body can become so single-minded that they often sacrifice relationships and career goals and may even stunt their emotional and physical growth. Other gay men, fearful of being or becoming “too fat”, will use cardiovascular activities such as jogging, running or aerobics to burn fat. Just as the anorexic can never be sufficiently thin, so the chronic exerciser can never get enough exercise.

Body Dysmorphic Disorders: Unlike healthy men, those with body image problems have no idea how they really look — and obsessively try to fix flaws that others don't notice. For many gay men, these “flaws” include the natural changes that the body experiences during the process of aging. Studies have shown that as many as 33% of men seeking cosmetic surgery have some form of body dysmorphic disorder. Although many gay men don't actually pursue surgery, they will nonetheless spend hundreds of dollars on potions, mail-order kits, and paraprofessional “clinics” in and endless quest to perfect their supposedly defective bodies. As a result, many of these gay men suffer loss of self-esteem and/or depression.

Steroid Abuse: Anabolic steroids (especially testosterone injections) are very effective in treating or preventing wasting syndrome in HIV+ men. But if a little is good, wouldn't more be better? Many HIV+ men, following this line of reasoning, are using more than the prescribed amount of testosterone to bulk up. And HIV- men, not to be outdone, have discovered that testosterone and other steroids can make them more muscular as well. In addition to the growing number of gay men abusing steroids, thousands more are buying millions of dollars' worth of “muscle-building” food supplements and diet aids.

Treatment Issues

As with many of the other psychiatric disorders treated at Pride Institute, the body image disorders we've seen respond well to a multi-modal treatment approach. A treatment plan incorporating psychiatric medication, cognitive-behavioral therapy and a Twelve Step support program is the most common and successful. For many gay men with prominent depression and/or suicidality as a result of severe appearance preoccupations, this treatment approach can have life-saving effects.

Psychiatrically, eating disorders and body dysmorphic disorders appear to respond particularly well to SSRI antidepressants such as Prozac, Paxil, Luvox, Zoloft, and Celexa. The beneficial effects of antidepressants typically don't appear for several weeks, so patience has to be stressed with gay men trying this option.

From a therapeutic perspective, cognitive-behavioral therapy seems to produce beneficial results in gay men with body image disorders. Cognitive-behavioral therapy has been demonstrated to be very effective in clinical studies for eating disorders; preliminary data suggest that it is also often effective for body dysmorphic disorders. The primary focus in therapy is challenging and changing the distorted thoughts which contribute to negative behavioral patterns.

Supporting cognitive-behavioral therapy are the Twelve Step recovery programs. Overeaters Anonymous (OA) and Depressives Anonymous (DA) are two very helpful recovery groups which focus on changing behavior and building support. Depending on the geographical area, other related groups may be available.

Conclusion

It is natural and normal for gay men to want to look good. There is absolutely nothing wrong with working out regularly at a gym, being a dedicated athlete, striving to eat a low-fat diet, or trying to maintain a healthy weight. Ordinary activities to improve body appearance are perfectly normal and justified. These behaviors become problematic or pathological only when they get out of hand — when the need to change one's appearance begins to cause emotional distress, undermines social relationships, or impairs in career performance or development. With proper assessment and treatment of body-related issues, mental health professionals can be instrumental in assisting their gay male clients to regain a comfortable acceptance of their bodies.

Resources:

Dutton, Kenneth R., The Perfectible Body: The Western Ideal of Male Physical Development, New York: Continuum, 1995

Pope, Jr., Harrison G., Phillips, Katherine A. & Olivardia, Roberto, The Adonis Complex: The Secret Crisis of Male Body Obsession, New York: The Free Press, 2000.

Signorile, Michelangelo, Life Outside: The Signorile Report on Gay Men: Sex, Drugs, Muscles and the Passages of Life, New York: Harper-Collins, 1997