As a young boy, Sam was used to people sharing their opinions on his body. Starting from the age of five, his parents frequently told him he was too skinny and that he needed to eat more. “Men need to be big,” he remembers his parents saying, so they could grow up and become providers for their families.
It was the start of what would become a lifelong self-consciousness about body size for Sam. After coming out as queer in college, Sam struggled to navigate what he described as “gay men’s hyper-fixation on the ‘perfect body,’” a culture that celebrates muscular, chiseled bodies as the pinnacle of queer masculinity. He became preoccupied with how his muscles looked in the gym mirror. His diet fluctuated along with his mental health, which was increasingly tied to his pursuit of a bigger, stronger-looking body.
“When I start worrying about my body, then my routine and overall health start to deteriorate,” said Sam, now 25, who asked that his last name not be used to protect his privacy.
As social media proliferates increasingly stringent beauty standards, research shows that the U.S. is experiencing an unprecedented rise in body dysmorphic disorder among young people across all genders. But muscle dysmorphia, a subcategory of body dysmorphic disorder, is affecting a growing number of men specifically. Driven by an anxiety that they aren’t muscular enough, experts say, more men and young boys are developing a compulsive relationship to exercise, dieting, and in some cases, steroid usage.
It’s a medical consequence of a broader cultural shift, in which higher and higher expectations for masculine bodies fuel demand for equally drastic health advice. This cycle is especially salient online, where men with various degrees of credentials dispense advice on how to gain muscle to an audience of millions.
Sam Sulek — an almost inconceivably large 22-year-old bodybuilder — has nearly 10 million followers combined on YouTube and Instagram tuning into videos like “The Bulk Day 105 – Chest – Heavy Incline and Thought Control.” His recent shirtless photo dump (caption: “End weight unknown”) garnered over 1.6 million likes on Instagram. Other influencers, like Jeremy Ethier and Jeff Nippard, outline the pros and cons of being an “enhanced” (steroid-using) versus “natty” (sans steroids) bodybuilder — an act of transparency that simultaneously normalizes steroids as it warns against their adverse effects.
As ideals about men’s bodies are steadily skewing toward the bigger and leaner, it’s taking a new kind of toll on young people.
“Men face a lot of direct pressures around bodies and fitness in modern society … that they wouldn’t have seen 20 years ago in the same way,” said Becca Boswell, a clinical psychologist and the director of the Penn Medicine Princeton Center for Eating Disorders. “And for many it feels like, ‘If I can’t meet these standards, then who am I to exist in the public arena?”
What is muscle dysmorphia?
Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a negative preoccupation with part of one’s own body, even in scenarios where that feature may be imperceptible or nonexistent to others. It’s associated with obsessive thinking patterns and compulsive behaviors, which can include restrictive eating, social withdrawal, and a dependency on mirror checking.
Muscle dysmorphia is a specific subtype of the disorder, in which the central fixation is on muscle definition and overall muscle mass. The term was first coined by researchers in 1997, though the condition was colloquially known as “bigorexia” or “reverse anorexia” within weightlifting communities for years before that.
Despite these comparisons to anorexia, experts told STAT that disordered eating is one of a wide range of possible symptoms of muscle dysmorphia. People with the condition have a compulsive relationship to exercise as well as to dieting, with many turning to anabolic steroids without medical guidance.
Muscle dysmorphia also has a high comorbidity rate with obsessive compulsive disorder, depression, and anxiety. Multiple experts told STAT that they’ve worked with patients who were unable to sustain relationships or jobs, or even attend social gatherings due to an overwhelming sense of fear and failure stemming from their perceptions of their bodies. And like other forms of BDD, muscle dysmorphia has a high correlation with suicidal ideation.
“A lot of people will treat it as a trivial sort of thing like, ‘Why can’t these people just look in the mirror and see that they’re muscular?’ And they treat it like it’s not a real illness,” said Mair Underwood, an anthropologist at the University of Queensland who studies muscle dysmorphia in bodybuilding communities. “But if people knew the level of suffering that comes with these illnesses, they wouldn’t be so quick to trivialize it and dismiss it as an issue of vanity.”
While an estimated 0.7–2.4% of the U.S. adult population is affected by BDD, it’s difficult to get a solid approximation of how many people suffer from muscle dysmorphia specifically.
This is in part because it’s only begun to be examined in clinical settings in the last couple decades. Another major reason is because most people with muscle dysmorphia are men, who are not only significantly less likely to seek help for mental health issues, but also often excluded completely from conversations about body image. It’s still a common misconception that eating disorders predominantly affect young white women. Yet data reveals that they affect people of all races, and some studies posit that as many as 40% of people with BDD are male.
“Men are often explicitly and implicitly discouraged from getting help for these struggles.”
William Grunewald, Ph.D. candidate at Auburn University
“Men are often explicitly and implicitly discouraged from getting help for these struggles,” William Grunewald, a Ph.D. candidate at Auburn University researching mental health risk and male disordered eating, told STAT. Grunewald believes this gender disparity stems from harmful cultural norms around masculinity, such as the idea that real men are self-reliant and can control their emotions without help.
Grunewald also points to the unique stressors faced by queer and non-cisgendered men, who may feel an added pressure to “prove” their masculinity in a culture that often seeks to diminish them, studies indicate.
Sam shared this sentiment, saying that in his experience, “Gay Asian men are often fetishized as submissive femme bottom twinks in the West … I subconsciously felt like I had to present my body as the opposite of that by being bigger with more muscles.”
Roberto Olivardia, a clinical psychologist and lecturer at Harvard University, helped first coin the term “muscle dysmorphia” in the 1990s. When he first began researching the condition, no one would respond to studies asking for male subjects struggling with body image.
“That term was almost inherently feminized,” he said. “Historically, women have been made to feel at war with their bodies in so many ways, so keeping your body ‘right’ has almost become synonymous with being a girl and being a woman.”
Such stereotypes about gender can result in devastating health outcomes. “When men get treatment for any psychological concern, they’re often sicker because they hold on to that illness for longer,” Boswell said.
For Will, a 27-year-old living in Detroit, the idea of openly sharing his concerns about his body with someone else never occurred to him. “This is maybe one of the longer conversations that I’ve had about this in my life,” he said, referring to his interview with STAT. “I’ve never had a relationship, friendship or whatever where I’ve talked a lot about my relationship with my body.”
Though he has never been officially diagnosed with muscle dysmorphia or an eating disorder, Will has always felt keenly aware of his own body’s appearance, and how it strayed from a certain “ideal” male body type. As a lanky high school student, he watched other classmates flirt and date and fall in love, and wondered if he was too unattractive to participate in such activities. When he went through a breakup in college, he coped by doing what he called a “canon male event” — throwing himself into weightlifting and maximizing protein intake. Being desirable, he explained to STAT, always felt inextricable with having a bigger, more muscular body.
“I just felt like I understood what a man’s chest and abs should look like, and that was very much the center of how male bodies were portrayed on TV,” said Will, who also asked to go by just his first name to protect his privacy. “I remember thinking a lot about that.”
Media and the perpetuation of unrealistic body standards have long gone hand in hand. But there’s a correlation between social media’s rise and the noticeable increase in boys — some as young as 9 or 10 years old — seeking help for muscle dysmorphia, according to Olivardia, who has worked with both adult and child patients on recovery for decades.
“There’s no question that social media has been this huge accelerant in a bad way in terms of body image,” Olivardia said. “It’s almost undeniable to me clinically.”
Social media has also made bodybuilding culture more accessible to mainstream audiences, Underwood said. Counting macronutrients and strict muscle-building training regimens were once almost exclusively within the realm of bodybuilders, but have since become much more common outside these circles.
On TikTok, for example, searching “building muscle” and “muscle growth” will result in 236.8 million and 95.8 million tagged posts respectively. YouTube is home to a plethora of videos covering 4,000 calorie diet routines, macronutrient ratio recommendations, and what exercises work best to get a “chiseled lower chest” or build “massive lats.” For diet specifically, there are scores of videos, forums, podcasts, and e-commerce articles devoted to weighing the merits of different protein powders for muscle gain.
For several years now, Google search interest in the benefits of steroid usage, as well as “bulking and cutting” — a muscle-building tactic that’s been used by bodybuilders for decades — has been steadily on the rise. Growing online discourse about how steroids impact bodybuilding has also been accompanied by greater access to purchasing said steroids. A quick online search on how to purchase the cattle steroid trenbolone, known affectionately as “tren” among its fans, will produce a litany of options including Amazon, eBay, and even SoundCloud. Altogether, steroid usage among young people has reached a new peak in popularity, with an estimated 6.4% of men who live in countries where they’re available using them worldwide.
The unique challenges of getting treatment for muscle dysmorphia
For many people with muscle dysmorphia, just acknowledging that you may have a problem can be challenging. Consistent exercise and eating well are part of a healthy lifestyle, but the line between rigorous self-improvement and a more mentally and physically debilitating condition can be blurry.
”Society tells us to exercise and watch what we eat, and deliberately shaping your body to look its best is common practice,” Underwood said. “So how do you know when it becomes a problem?”
That distinction becomes especially murky online, where more extreme dieting and exercise regimens are shared freely. “Oftentimes fitness advice is conflated with what appears to be disordered eating,” Grunewald said. Fitness content targeted toward masculine audiences also frequently presents its diet and exercise advice as “scientifically proven,” a descriptor that many viewers may take at face value, without considering variables like age or pre-existing health conditions.
“Even if someone feels like they’re striving for health and wellness, the question becomes at what cost?”
Becca Boswell, director of the Penn Medicine Princeton Center for Eating Disorders
Counselors who work with muscle dysmorphia patients said that many people are not willing to seek help until a major life event forces them to reevaluate their choices, such as going through a breakup, losing their job, or getting severely injured. This unfortunately makes sense, Underwood argues, because it usually takes a dramatic change of environment for people to stop normalizing the disorder.
Speaking on the insular nature of the bodybuilding community, Underwood said, “You can put a post online, for example, saying, ‘My partner’s complaining about the amount of time I spend in the gym,’ and you’ll watch everyone go, ‘Dump them! They don’t understand you.’… It’s very hard to get perspective, especially when you’re surrounded by people who also have no perspective.”
To discern whether someone’s body dysmorphia veers into disorder territory, experts suggest digging deeper into what’s motivating their compulsive relationship to exercise: “Even if someone feels like they’re striving for health and wellness, the question becomes at what cost? And if it’s at the cost of their relationships or their time for everything else or for their bodily health, then it’s no longer about wellness,” Boswell said.
What does recovery look like?
Because muscle dysmorphia impacts people on a physiological, psychological, and social level, the process for recovery is similarly multifactorial. At the Princeton Center for Eating Disorders where Boswell works, the first step for patients is making sure they’re physically healthy enough to receive care — whether that means eating enough food or easing off of steroids, which are linked to increased mental health risks.
Psychological treatment varies from patient to patient, depending on the severity of that person’s diagnosis, but generally focuses on two main priorities: Unpacking the motivating factors behind compulsive behaviors, and accepting that these behaviors are not sustainable.
In therapy, Boswell aims to guide patients in their own understanding of muscle dysmorphia. “What was the function of this pattern of behavior? Was it to create a sense of control?” she said. “Did it help create a sense of achievement and protection from social judgment?”
Answering these questions, Boswell said, can eventually help patients practice exposure and response prevention, a form of behavioral therapy that teaches patients to acknowledge triggering stimuli without engaging in anxious or compulsive behaviors.
Similarly, Olivardia focuses on helping patients transition from a compulsive diet and exercise routine to one that’s more balanced. It can be tricky at first, he explains, because unlike alcoholism or substance abuse, the goal of muscle dysmorphia recovery is moderation, not abstinence.
“The goal is not to have these men never exercise or lift weights again,” Olivardia said. “It’s about how to engage in that arena in a more regulated fashion, and building the skills and support to make that happen.”
Pushing back against body image pressures
All the psychologists and researchers STAT spoke to emphasized one crucial psychosocial component of muscle dysmorphia recovery: The inevitability of encountering stimuli that trigger body self-consciousness or shame.
“I can’t immunize my patients from being triggered. We live in a culture where it’s all around us,” Olivardia said.
Certain body types receiving more praise and attention than others is an inescapable cultural reality, and patients need to be prepared for exposure to marketing, products, and societal discourse that condone body dysmorphia in everyday life. Beyond individual medical attention, experts argue that truly addressing muscle dysmorphia and other forms of BDD would require a fundamental overhaul of how society talks about what bodies “should” look like.
“There is a real cultural component to the body image pressures that people are tied to,” Boswell said. Reducing muscle dysmorphia risk on a societal level, she argues, means considering “whether ideals about bodies and health and wellness are making us sicker.”
Ironically enough, some of that change is beginning to happen on social media. Among the onslaught of pro-muscle growth content online, there’s a small but growing contingent of men willing to speak openly about the mental health risks of muscle dysmorphia.
Jeff Nippard, a bodybuilder, fitness coach, and YouTuber with over 6 million subscribers, has discussed his own previous experiences with body dysmorphia. “In almost everyone I’ve ever coached, confidence and body image improve as they get leaner, but only up to a point,” he said on YouTube. “A switch flips in their brain and they can no longer see their physique objectively. They start noticing every little bit of fat on their body and get very critical about how they look.”
Mike Israetel, a bodybuilder and former sports physiology professor, advised people in a recent podcast to pay attention to their negative thoughts and comparisons to other people’s bodies, and question whether that’s a helpful training mindset. “Hating yourself as a motivation is the shortest fuse in the world,” he said.
Social media can also highlight a diversity of different body types, a reminder that there is not a singular ideal way for the human body to look.
“Something that helped me a lot was seeing on TikTok, YouTube — just seeing on social media people recognizing and sharing their attraction to all different types of people,” Will said. “I think seeing that bandwidth and understanding like, everyone is capable of being loved and attractive feels like it takes the weight off. You feel like you don’t feel like you have to earn it.”
These gradual cultural shifts may seem subtle at first, but experts insist it’s part of the long-term fight against body dysmorphia. “If we’re going to rely on men to identify this themselves and find their own way out of it, that’s not going to happen,” Underwood said. “Society needs to help them recognize that this is a problem.”