The terms “eating disorder” and “body dysmorphia” may bring to mind images of an already slender young woman going to dangerous lengths to become even slimmer, or looking at herself in a mirror and seeing in her reflection something radically different than is actually there. But these physically and psychologically damaging behaviors are not unique to women. In an age where we have at our fingertips photoshopped pictures of bodybuilders and male models with chiseled physiques and not an ounce of body fat in sight, men and boys are increasingly affected by the drive to achieve the perfect body. We explored the concept of “atypical anorexia” in a recent article and a previous article delved into body dysmorphia. This time, let’s take a closer look at how the desire for physical perfection may have a negative impact on the physical and emotional health of men and boys.

While women may gravitate toward a “thinner is better” perspective, men may be more inclined to be swayed by images of popping muscles, with a “bigger is better” attitude toward pecs, biceps, and delts. Researchers use the phrase “muscle dysmorphia” to describe “a condition characterized by a misconstrued body image in which individuals interpret their body size as both small and weak even though they may look normal or even be highly muscular.” Others have described it as “a pathological preoccupation with muscularity” and “a form of body dysmorphic disorder with a focus on muscularity.” People have also used the terms “reverse anorexia” and even “bigorexia,” which highlight the drive to become larger rather than smaller.

“Addiction to body image” has been proposed as an alternative to muscle dysmorphia because it may more closely fit and better explain the associated behaviors. Researchers claim that by emphasizing the addictive nature of the condition, it puts front and center the continuing of certain behaviors perceived as being beneficial or necessary, but which in reality may cause long-term harm. (Such behaviors could include excessive exercise, taking anabolic steroids, neglecting important social or professional activities due to spending inordinate amounts of time in the gym or spending excessive amounts of money on specialized foods and ineffectual supplements.)

Beyond these potentially harmful behaviors, males with muscle dysmorphia may be at increased risk for substance abuse and attempting suicide. Although muscle dysmorphia can clearly have a major negative impact on the quality of life in those afflicted—extending to the taking of one’s own life—the condition is not yet classified as an individual entity in psychiatric diagnosis. It is, however, categorized with other Body Dysmorphic Disorders (BDD) in the International Classification of Diseases (ICD-10). Researchers have proposed classifying it as a distinct eating disorder entity, explaining that this “may offer more clinical utility in recognizing the male experience of eating disorder pathology and also help reduce the number of current male cases falling into the EDNOS [eating disorder not otherwise specified] category.”

Muscle dysmorphia is just one variant of BDD. An Australian study found that muscle dysmorphia occurs almost exclusively in males, but BDD, in general, afflicts males and females at similar rates and is frequently unrecognized. (Even trained physicians and other healthcare professionals might find it difficult to distinguish between healthy, appropriate goals regarding diet and physique and dangerous obsessions with “clean eating” and physical perfection.) Another phrase that’s been used to describe the unhealthy fixation on muscle mass is “muscularity-oriented disordered eating” (MODE). It may be difficult to recognize this because, as one paper pointed out, this kind of behavior may be considered “goal-oriented” if it occurs in boys or men involved in sports or competitive athletics. (Similar to the female athlete triad: behaviors that at first may confer a competitive edge become detrimental over the long term.)

Chasing ever-larger muscles isn’t the only physique goal that can lead to problematic behavior in men. Idealizing thinness may also result in disordered eating. Additionally, some males may “transition” from disordered eating centered around thinness to that centered around muscularity. For a male living with anorexia, it could be considered a positive step if he chooses to consume more food in an effort to put on muscle mass, but if this new muscle-oriented eating behavior escalates into something pathological, it is not necessarily an improvement.

A prospective cohort study involving young males (age 12-18 at baseline) who were followed for approximately 12 years and assessed via questionnaire every 12-36 months showed that independent of age and BMI, boys with high concerns about thinness were more likely to develop depressive symptoms, while those with high concerns about muscularity were more likely to start binge drinking or using drugs. Clearly, the consequences and potentially harmful risks of being dissatisfied with one’s physique go far beyond chugging an extra protein shake now and then or missing a night out with the guys in favor of an evening date with a squat rack.

Eating disorders in males are underdiagnosed and undertreated. They may also manifest differently in males and females. Males are generally more prone to problematic behavior with a goal of gaining weight rather than losing it, but it would not be surprising to see this shift with rising rates of obesity. Additionally, research indicates men are less likely than women to engage in vomiting or laxative abuse as a form of purging in bulimia, turning instead to excessive exercise for control of body weight, which could present different adverse health effects, making it more difficult to diagnose.

One paper’s authors acknowledged a systemic problem that may be an obstacle to men seeking help when their healthy behaviors cross the line into dangerous territory: “Encouragement of a culture which allows for male vulnerability is a major goal. Men are not supposed to be emotionally vulnerable in our present culture, yet they encounter pressures on a daily basis to be more muscular and meet the current male body shape ideals.” Doctors and nutritionists can play an important role in helping to identify disordered eating among male patients and directing them toward resources to get help. It starts with professionals being aware of how widespread the problems are, and how often they go unrecognized. Men may be more inclined to be honest about their behavior when an understanding professional opens the conversation first.