Body dysmorphia in gay male spaces: the double binds of knowing what you want and simultaneously rejecting it

Abstract

Body Dysmorphic Disorder (BDD) is a distressing mental health disorder with a prevalence of 2.4% among adults in the United States. While research has previously evaluated the impacts of age and gender differences, there has been a limited focus on the intersection of BDD symptomology and the experiences of sexual minority men. This dearth of research contributes to a lack of understanding, both socio-culturally and clinically, of the lived experiences of gay men with BDD. This qualitative study explored the lived experiences 10 self-identified gay men diagnosed with BDD to gain insight into possible intrapsychic and interpersonal factors that are at play for this population. Analysis, informed by a phenomenological approach, yielded three key themes of double binds experienced by the participants: My Armor is my Spotlight, Wanting Intimacy but Rejecting it, and Caught Between Cultural Expectations and Desires for Self.

LAY SUMMARY

Body Dysmorphic Disorder (BDD) is a mental health disorder diagnosed in a person who reports preoccupation with one or more perceived flaws or deformities in their appearance. While literature has explored the impacts of BDD with gender differences, scarce research has been done on the effect of sexual minority men. This study interviewed 10 self-identified gay men diagnosed with BDD to gain insight into possible psychological and interpersonal factors that are at play for this population and to better help them.

Keywords:

• Body dysmorphic disorder
• sexual minority men
• LGB community
• qualitative
• phenomenology
• gay male culture
• double binds
• intraminority stress

Introduction

Body Dysmorphic Disorder (BDD) is a mental health disorder that may be diagnosed in a person who reports preoccupation with one or more perceived flaws or deformities in their appearance that are slight, or not perceptible to others [5th ed.; DSM-5; American Psychiatric Association (APA), 2013]. The individual may also engage in repetitive monitoring behaviors and/or avoid everyday activities (Morgan-Sowada & Gamboni, 2021; Rief & Buhlmann et al. 2006). While there have been numerous studies describing a fraught relationship to body image in sexual minority male populations, there is an extremely limited pool of research specifically evaluating BDD in gay men (Boroughs et. al, 2010; Morgan-Sowada & Gamboni, 2021). Gay men live within a complex sociopolitical context and prior research suggests an increased prevalence of both eating pathology and body dissatisfaction among sexual minority men relative to heterosexual men (Convertino & Helm, 2021). While there are theories regarding what may be driving this disparity in body dissatisfaction broadly, limited attention has been given specifically to the intersection of BDD and gay male identity (Brennan et al., 2013; Convertino & Helm, 2021; Frederick & Essayli, 2016; Meyer, 2003; Pachankis et al., 2020).

BDD definition and prevalence

BDD was re-classified in the DSM-5 under “Obsessive-Compulsive and Related Disorders” to more accurately reflect the experience of BDD from its prior classification under somatoform disorders. The key distinction in the classification shift is a new diagnostic criterion: at some point over the course of the disorder, the individual must have engaged in repetitive behaviors or mental acts in response to concerns around their appearance (Scheiber & Kollei et al., 2015; APA, 2013). In addition, BDD may be diagnosed in an individual who reports preoccupation with one or more aspects of their appearance that is perceived to be deformed and these experiences must lead to clinically significant distress or impairment and must not be better explained by weight concerns whose symptoms meet the diagnostic criteria for an eating disorder (DSM-5). Muscle dysmorphia is a specific sub-criterion that is indicated by an excessive preoccupation with musculature. This sub-criterion is seen almost exclusively in the male population (DSM-5).

The most common age of onset for BDD is 12-13 years old and the average age of onset is 16-17 years of age (DSM-5). The prevalence of BDD in the U.S. has been found to be 2.4% across the general population; however, Boroughs et al. (2010) has found evidence that BDD symptoms are more prevalent among sexual minority men relative to heterosexual men. BDD is a distinctly different diagnosis than eating disorders: however, the two are commonly comorbid and it is unsurprising that a population with a higher prevalence of eating disorders and body dissatisfaction would also yield a higher prevalence of BDD (Boroughs et al., 2010; Calzo et al., 2017; DSM-5; Frederick & Essayli, 2016).

Double bind theory

Double bind theory within the field of psychology originated with Bateson, Jackson, Haley, and Weakland who were seeking clarity on the “nature of schizophrenic communication” (Watzlawick, 1963). In their report “Toward a Theory of Schizophrenia”, the researchers defined a double bind as feeling placed in a position where there is no “good” choice to be made and one “can’t win” (Bateson et. Al., 1956; Watzlawick, 1963). The originators understood that all double binds had the potential to be highly distressing and could influence panic or rage (Watzlawick, 1963). Though double-bind theory has its roots in the study of schizophrenia, it has more recently been applied to body image. In a 2008 article, Yokoyama utilized double bind theory to examine the impacts of racism and sexism on body image and eating disorders among Asian American women. The conclusion of “The Double Binds of our Bodies” highlights the criticality of considering the impact of sociopolitical contexts on body image (Yokoyama, 2008).

Intraminority stress and objectification theory

As mentioned previously, the literature has not identified a root cause of the disparity in body dissatisfaction and eating pathology: however, there are several potential theories (Brennan et al., 2013; Convertino & Helm, 2021; Frederick & Essayli, 2016; Meyer, 2003; Oshana et al., 2020; Pachankis et al., 2020.) The minority stress model, established by Ilan H. Meyer (2003), posits that sexual minority population experience stress related to social stigmas and constraints stemming from broad societal views of their identity and, furthermore, that this added stress can lead to increased rate of psychopathology, including disordered eating (Meyer, 2003; Convertino & Helm, 2021). The minority stress model sees community involvement as a key protective factor for the increased vulnerability to poor mental and physical health outcomes; however, a recent study examined cultural factors, such as body image ideals, within the gay community noted the ways intraminority stress may negatively influence the mental health of gay and bisexual men (Pachankis et al., 2020). Previous research suggests that men in general tend to engage in competitive behavior surrounding sexual and social gains (Brennan et al., 2013: Pachankis et al., 2020). Given that sexual minority men engage with other men for both social and sexual relationships, status-based competitive pressures among sexual minority men may be a factor (Brennan et al., 2013: Pachankis et al., 2020). Furthermore, the distribution of social capital within the gay community mimics that of larger society, in which racial and ethnic minorities, those who are older, disabled, HIV-positive, or bisexual hold less power than those who are young, white, and fit; these in-group disparities influence negative health outcomes as well (Brennan et al., 2013; Pachankis et al., 2020).

Objectification theory posits that men’s treatment of women as sexual objects may translate to women also seeing themselves as sexual objects. This internalization can lead to self-surveillance and hyper focus on their presentation to the world (Frederick & Essayli, 2016). Lanzieri and Hildebrandt (2016) applied the lens of objectification theory to the literature outlining a more prevalent desire for increased muscle tone and increased levels of body dissatisfaction among gay men relative to straight men. In this context, it is argued that some gay men may internalize the white, muscular, standards of perfection portrayed in the media (Lanzieri & Hildebrandt, 2016). This internalization of appearance standards by gay men via pressure from media has been well documented (Brennan et al., 2013; Frederick & Essayli, 2016).

Sexual minority men and body image

The existing literature examining the relationship between gay and bisexual men and their bodies has found that sexual minority men are at an increased risk for body dissatisfaction and eating disorders relative to heterosexual men (Frederick & Essayli, 2016: He et al., 2020). Frederick and Essayli (2016) examined the results of five national U.S. studies focused on the intersection of sexual orientation and body image. Their analysis found that gay men tend to be more invested in appearance and more interested in body modification than their heterosexual counterparts (Frederick & Essayli, 2016). An additional finding, which has been corroborated by other studies, is that gay men report experiencing pressure to conform to appearance ideals portrayed in media (Brennan et al., 2013; Frederick & Essayli, 2016; Morgan-Sowada & Gamboni, 2021).

The projection of an ideal body image within gay male culture skews masculine, muscular, and white and may be perpetuated by a felt sense of ever-present expectations of perfection (Brennan et al., 2013; Lanzieri & Hildebrandt, 2016; Morgan-Sowada & Gamboni, (2021). Those who fall outside of this ideal, such as men with a minoritized racial identity, report distressing experiences of being ignored, invisible in media, and/or fetishized. These compounding experiences may contribute to additional vulnerability to negative health outcomes, including disordered eating and promiscuity as a tool for feeling accepted and validated (Brennan et al., 2013; Pachankis et al., 2020).

While the literature supports the finding that sexual minority men are at an increased risk for body dissatisfaction (Convertino et al., 2020; He et al., 2020; Lanzieri & Hildebrandt, 2016), only one known study examines the role of in-group culture on the onset and experience of Body Dysmorphic Disorder in sexual minority men (Morgan-Sowada & Gamboni, 2021). A qualitative study by Morgan-Sowada and Gamboni (2021) found that all 10 of their participants described feelings of frustration, animosity, and contempt towards gay male culture and placed blame on the in-group cultural norms for perpetuating their BDD symptoms. Furthermore, 6 of the10 participants indicated their onset of symptoms began around the age of 18, coinciding with coming out and beginning to participate in the gay community. The typical age of onset for BDD is 12-13 years of age (Morgan-Sowada & Gamboni, 2021; DSM-5). Those who had onset prior to coming out reported feeling an escalation in symptoms once joining the gay community (Morgan-Sowada & Gamboni, 2021).

Purpose

The research discussed in the previous section has provided important contributions to the BDD literature (Boroughs et al., 2010; Calzo et al., 2017; Convertino et al., 2020; Frederick & Essayli, 2016; Scheiber & Kollei et al., 2015; APA, 2013) and the intersection of body image and gay identity (Boroughs et al., 2010; Brennan et al., 2013; He et al., 2020; Lanzieri & Hildebrandt, 2016; Morgan-Sowada & Gamboni, 2021). However, there has been only one study the authors are aware of that examines the impact BDD specifically can have on gay men. The qualitative study found that cultural norms and social pressures within the gay community can yield an experience of BDD for gay men that has unique markers from the experience of BDD in the general population (Morgan-Sowada & Gamboni, 2021). The present study seeks to build upon the findings of Burroughs et al., (2010) and Morgan-Sowada and Gamboni (2021) by examining the socio-cultural factors that may be influencing the ways in which the experience of BDD can be different for gay men.

Methodology

Design

Since this study seeks to examine the lived experiences of gay men with BDD in gay spaces, phenomenology was used as the central methodological approach (van Manen, 1990). Phenomenological studies attempt to explore the meanings that are inherent to an individual’s lived experiences and places significance on identifying an individual’s perception, beliefs, and awareness of the phenomenon being examined (Creswell, 2013). Phenomenological research is interpretive, rather than descriptive (van Manen, 1990). Because the underlying goal of this design is to give a voice to the individual about their personal interpretation of their experiences, phenomenology is the appropriate method for this study.

Due to wanting to garner the rich descriptions of these gay men’s experiences, over the phone interviews were the primary mode of data collection throughout this study. A pre-interview questionnaire was administrated by Qualtrics, a secured database for online survey software, which was then followed by an over the phone interview that took place once participants fulfilled the inclusion criteria.

Recruitment and participants

Phenomenological research provides the opportunities for researchers to not only “raise” the questions presented, but also “live” or “become” the questions (van Manen, 1991). The first and third authors live with BDD and the first author has the duality of being a gay man with BDD. The second author identifies as queer and while not diagnosed with BDD, has a complex relationship to the body and is broadly invested in the health and well-being of gender and sexual minorities. We as researchers believe that our personal experiences were linked to how we interpreted literature provided and analyzed participant disclosures. Significance is placed on locating the individual’s beliefs, awareness of, and personal meaning of the phenomenon being studied (Creswell, 2013). In order to bracket any biases that arose, researchers engaged in reflexive journaling and peer debriefing to ensure the trustworthiness of the data analysis process.

This study was given Institutional Review Board (IRB) approval prior to the participant recruitment. Recruiting advertisements were posted on online BDD support group forums found on the social media platform Facebook. Imbedded in this advertisement was the link to the Qualtrics survey that participants were prompted to compete. Informed consent, which included details regarding participant’s right to refuse participation, confidentiality, and potential risks and benefits to the study was included in the online Qualtrics survey. Once the survey was completed, all participants were provided information to contact The BDD Foundation, where they can locate a therapist in their area if needed, and The National Suicide Prevention Lifeline. Inclusion criteria for this study consisted of being at least 18 years of age and self-reporting as being a gay male and self-identifying as having BDD. Once informed consent was given potential participants were instructed to answer questions that screen for the presence of BDD. The participants in this study were considered self-diagnosed with BDD, and eligible for the study, if they responded “yes” to screening questions found on the Body Dysmorphic Disorder Question (BDDQ) for Adults (Phillips, 2005), an impactful and commonly used questionnaire asking participants around their concerns with body appearance. Ten individuals participated in this study. The description of demographics (Table 1) which was collected utilizing the Qualtrics survey is below.

Table 1. Participant description.

Pseudonym	Gender Identity/Pronouns	Age Range	Race/Ethnicity
Ted	Male (He/Him/His)	45+	Caucasian
Fades	Male (He/Him/His)	25-34	Mixed Race
Anthony	Male (He/Him/His)	18-24	Caucasian
Lawrence	Male (He/Him/His)	25-34	Caucasian
Robbie	Male (He/Him/His)	18-24	Caucasian
Carlos	Male (He/Him/His)	25-34	Hispanic/Latino
Jay	Male (He/Him/His)	25-34	Hispanic/Latino
Ross	Male (He/Him/His)	25-34	Caucasian
John	Male (He/Him/His)	25-34	Caucasian
Matías	Male (He/Him/His)	45+	Hispanic/Latino

Data collection

Ten semi-structured, open-ended interviews were administered by the third researcher to participants where they discussed their lived experiences of being a gay man with BDD. The interviews conducted ranged from 45-60 min in length. All interviews took place over the phone utilizing a cellular recording application to record each interview. To be able to triangulate the data, the same Qualtrics survey demographic questions were asked during the interviews. The interview protocol included questions pertaining to the intersection of participants experiences with BDD and how their BDD and views of self is impacted when in gay spaces.

Data analysis

Data was analyzed utilizing thematic analysis. Thematic analysis involves open coding, creating axial codes, and generating group themes (Saldaña, 2015) along with creating themes and configurations from the qualitative data collected (Merriam, 2009). The researchers developed an organized method system for gathering, coding, and consolidating each participant’s data. Through open coding, the over the phone interviews and demographic questionnaire were transcribed by the researchers and placed into categories of codes created utilizing a color-coding system. Reduction places emphasis on continuously lowering the phenomenon of choice to its core meaning (Merriam, 2009). This method was used when comparing codes throughout both open and axial coding processes. As a result, the goal is to be able to create insight of the participant’s experience with said phenomenon, for these participant’s it was the lived experiences of gay men with BDD in gay spaces.

To ensure codes were ongoing throughout data analysis, open coding continued past saturation (Rossman & Rallis, 2012). The concepts that were formed during open coding were collapsed into axial codes formed by codes relating by constantly comparing the categories (Saldaña, 2015). Throughout this process, generating themes took place and became apparent. The researchers then derived three major themes with each theme having three elements based off of data collected.

Trustworthiness methods

Data triangulation

To offer validation and credibility to this qualitative study, data triangulation was used as an influential strategy throughout analysis (Rothbauer, 2008). A variety of data gathering techniques such as the over the phone interview transcripts, the Qualtrics survey, and reflexive journaling and analytic memos were used to triangulate data to establish trustworthiness (Merriam, 2009). Due to participant interviews being the primary source of data collection, the researchers wanted to increase trustworthiness by utilizing data analysis of the interview protocols and online surveys and comparing codes derived from these two sources. This enabled cross validation of the data collected.

Self-reflexive journaling

The researchers had a self-reflexive journal to focus on transferability. The researchers wrote any hesitations, inflictions, or laughter throughout the 10 over the phone participant interviews. Initial impressions, possible biases, and early potential themes were journaled to assist in any transferability. The notes highlighted in these journals helped assist the researchers in developing of themes and elopements. To ensure that the researcher’s biases did not influence the way data was interpreted, bracketing was used by making our interpretations and opinions about the interviewees and codes created explicit to all participants (Rossman & Rallis, 2016).

Member checking

To make sure each participant’s voice was properly represented, the researcher accomplished member checking (Saldaña, 2015). Once the over the phone interviews were transcribed, the researchers sent a copy of the transcription to the participants as an opportunity for them to make any corrections they felt necessary. Their emails were collected through the Qualtrics survey, and each participant was given one week to contact the researchers to provide any clarifications necessary. All participants confirmed that their experiences were accurately portrayed. One participant offered clarification on a comment made within the interview which assisted in richer findings.

Researcher as the instrument

Phenomenology is a qualitative research method that holds the researcher as the primary instrument for data collection and data analysis (Saldaña, 2015). Due to the main mode of data collection being over the phone semi structured interviews, researcher as an instrument plays a crucial role in data analysis because of the potential researcher influence on empirical materials (Creswell, 2013). The first author is a gay, Caucasian, cis male who has a diagnosis of BDD. His struggles with being in gay spaces due to body projections, judgments, and shame from other gay men has inspired the study. He has also found great solace in the music of the gay male community and sees significance in the intersection of music and the gay male populations. The second author is a queer, Caucasian, gender-fluid individual with close relationships to gay men who struggle with self-perception and body image. The third author is a straight, Caucasian, cis gender female who has been diagnosed with BDD. She specializes clinically in treating BDD and working with the LGBTQ population.

Results

Qualitative analyses were conducted to examine the experiences of gay men with BDD and the ways in which their sexual identity and BDD may inform each other. The analysis was divided into three themes: My armor is my spotlight, Wanting intimacy but rejecting it, and Caught between cultural expectations and desires for self. Each theme contains two subthemes which hone the specificity of the findings.

Theme #1 - my armor is my spotlight

This first theme explores double binds experienced by gay men with BDD which center their relationship to outward appearance. Participants reported utilizing tools and strategies to control the appearance of their material bodies, as well as how they adorn their bodies, as a means for concealing or altering elements of their appearance that are impacted by the experience of BDD. Participants disclosed how the elements of their external presentation they would change, as an attempt to soothe their BDD and protect themselves from the pain of those symptoms, or the armor, became a source of unwanted attention in and of themselves, drawing awareness to the very part of them they were seeking to hide, the spotlight. This double bind inadvertently creates a recursive cycle.

Physicality

Four participants indicated that they experienced a double bind in which they use an aspect of their corporeal appearance as a form of protection from either internal or external struggles. These protective mechanisms subsequently draw attention to the participant in a way that is undesirable and inadvertently reinforces the BDD. This first participant, Ted, gained weight in part as an attempt to protect himself from the sexual trauma he experienced as a child, however the weight became a point of ridicule from those around him. In an effort to reduce the negative feedback about his body, and to feel desirable, Ted oscillated towards becoming dangerously thin.

I just needed to protect my body because fat people don’t get messed with…The problem I am having now is that it has been beaten into me that “if you would just lose weight, you would be happy. Then you would be handsome. Then you would be loveable, then you would be dateable. Well that was a lie. I am now anorectics and underweight. If I keep going the way I am my specialist told me I would have to go to a treatment center and that I would hate it

For Robbie, the authentic “effeminate” behavior he embodies, which felt congruent with his identity as a gay man, became a spotlight after he came out as a trans man. The behavior, such as, “[speaking] more “stereotypically” gay [and using] a lot of body language like that” was a projection of his identity which had been embraced prior to coming out and afterwards became a source of rejection. Robbie’s experience of BDD is interwoven with his experience with gender dysphoria, as he states, “two separate but both hard issues.” In essence, this participant is faced with a choice of living authentically, both in his self-perception and in the perception of others or being rejected.

Yes. I’ve always been very "effeminate," so when people did not know I was trans, they assumed it was just being a “woman.” once I came out as a gay male, though, my "effeminate" behavior became immediately shunned by people who previously liked me”

An aspect of Carlos’ experience of BDD included a preoccupation with appearing thin and maintaining a 90-pound benchmark (American Psychological Association, 2013). Carlos’ hyperfocus on his weight began when his peers began teasing him for being thin, at which point he weighed 90lbs. This experience highlights a complicated dynamic in which the teasing, at once a source of pain, also enforced a specific notion of what his body should look like.

I do remember when I was little, I was being teased for being skinny. And for a really long time I weighed 90 pounds and checking myself on the scale and still be 90 pounds. I don’t know why. I just remember thinking I didn’t want to weigh heavier than that and the first memory I have of paying attention to my body.

Ross, who signaled a double bind rooted in physicality, relies on the gym for building his armor. He experiences the double bind as a compulsion go to the gym with great frequency to feel some relief in the context of his experience of BDD. However, satisfying the physical compulsion has invited commentary from friends and led to his absence from social gatherings. Ross shared, “They also comment on the amount of time I’m [at] the gym. Every day for 1.5 h and there are days where I have missed out on events to prioritize the gym”. Ross’ emphasis on going to the gym at the expense of social engagement speaks to the social impact and clinical significance of his pursuit of armor.

Adornment

As with the physicality subtheme, there were four participants who reported donning armor that yields unwanted attention. However, for this subtheme, rather than changes to the physical body, the participants’ armor is in the form of adornment. Lawrence indicated the use of, and being called out for, adornment as early as 7^th grade.

[In] 7^th grade I would utilize things like glittered lotion, and 7^th grade math class [I remember the] teacher saying, “turn your glittery face around!” I knew at that point it was noticeable to others, a problem, but I had no idea where to place that knowledge or those thoughts

This same participant grew to be an avid make-up user. On the one hand, the make-up provided a way for the participant to control his appearance. On the other hand, the make-up became a complicated signifier of both queerness and compulsive behavior reinforcing the BDD.

I was wearing a full face of makeup…a friend of mine later came out as lesbian, she would state that my use of makeup was a determining factor that I was gay and that there was no question I was on the spectrum… As I said about the cliché and stereotypes, and from a BDD standpoint, that because I looked the way I did…the way my body looked, that I was thin, and everything…that I was also then writing my own death sentence. I could not be anything else because I could not be anything else.

This next participant, Robbie, wants to adorn himself with clothing items that are traditionally coded as feminine, however doing so draws a spotlight to femininity in a way that undercuts others’ perception of his gender identity.

I love things like heels and purses and floral tops, and I do speak more “stereotypically” gay, use a lot of body language like that too, But I’m afraid to allow myself to fully express that [so I try to hide it due to fear of judgement, even though it’s natural for me to behave that way, and I shouldn’t have to hide], because people may see me in ways that deeply frighten and unnerve me. I feel I can’t truly be myself if I don’t have the looks that LET me be myself.

The very elements of adornment that help Robbie feel secure in his self-perception and that help to relieve BDD symptoms are noticed and rejected by cis-normative communities, gay and straight alike, the participant has access to. This rift leads to his identity being invalidated and misinterpreted by others. As a result, this participant must choose between an internal rejection of an authentic projection of himself or external rejection by those around him, thus reinforcing the BDD.

Ross shared a description of a double bind in which his choice to adorn himself with oversized clothing to hide his body ends up drawing attention to his body because people notice the oversized clothing. He states, “I wear clothing as a way to hide my body. Like I’m a medium and wear XL and they would ask why don’t you wear clothes that fit?”. Ross’ experience highlights how oversized clothing acts as an armor against the discomfort surrounding people being able to perceive his body caused by the BDD. However, that armor yields attention to the very part of himself he was attempting to protect with the armor.

Jay, the final participant within this subtheme shared a double bind in which the adornment that brings relief to the BDD and its impact on his feelings about his body yield a specific reaction from his partner: “If I wasn’t feeling good about myself or I ate too much I would always sleep with a shirt on. Ummm which was strange for him… So being in love and having restriction was unfortunate”. Once again, this participant is reinforcing that the strategies used to protect from painful feelings about oneself, as they relate to BDD, can also become the very thing that draws attention to the part of themself they were attempting to hide.

Theme #2 – wanting intimacy but rejecting it

This theme explores a double bind experienced by gay men with BDD within their romantic and sexual relationships. In both relational contexts, participants reported desiring romantic and/or sexual intimacy yet when those desires had the potential to become realized, they rejected them for reasons related to an activation of BDD symptoms.

Romantic

Wanting a romantic connection but rejecting it will be examined first. Robbie, who was noted earlier to experience an interplay between BDD and gender dysphoria, struggles with pursuing romantic relationships for two separate but related reasons. First, out of concern that the men he is interested in will not validate his gender identity. As he states, “It’s hard for me to initiate relationships with men, because I do fear they’ll see me as a woman and not a man”. Second, “I can’t even date anyone because I just get too jealous of them. I only like bigger/fat men, so I will always feel jealous if I were to date at all. I just wish I could look like them, and it makes me feel not good enough.” Robbie, despite endorsing loneliness, rejects the potential for romantic connection due to the ways in which engaging romantically with men foster a context that is discomforting for his experience of his body through both the lens of BDD and gender.

Jay maintains a strict criterion for people he will consider dating. This restriction stems from a powerful desire to maintain his compulsion for going to the gym for extended periods of time each day and a fear that having a boyfriend could derail his physical goals by interrupting this pattern. The specificity of the expectations leads him to avoid dating in general, thereby engaging more deeply with BDD than with social or romantic relationships, creating a negative impact (APA, 2013).

I fear that a relationship will cause me to eat and watch TV and that isn’t what I want to do right now for fear of losing everything I have been trying to get. I have been trying to get better [a better body] and it impacts future relationships…

He goes on to explain, “Being in a relationship… umm I think it sets rules and makes up rules of who this person has to be, which then prevents me from even looking because they don’t meet up to rules in my head.” Here Jay identifies that being in a relationship feels like a threat to his body image. His very real fears of not having a “better” body keep him from being vulnerable and open to romantic relationships He added, “If I can find someone on the same page with lifestyle, then I can allow myself to move on and be close to them.” Again, the BDD appears to be reinforcing “rules” that Jay must follow to compensate for BBD’s cruel messages of never being good enough.

These next three participants: John, Ted, and Anthony, respectively; share an experience wherein their internal narratives of themselves in terms of their appearance constrain their ability to internalize positive feedback and make desired connections. John, as stated next, will avoid social gatherings and investment into potential romantic connections because of intrusive thoughts about how others may be perceiving him.

I noticed a lot of time I will skip out on going out with friends because I am more nervous that they will find me disgusting. It interferes when I flake or cancel on plans. I’m assuming they’ll find me gross. Isolating. It doesn’t keep me from going to work but it keeps me from growing relationships or going on dates.

Ted’s desire to date has brought him to dating websites. However, disappointment with the effectiveness of the websites for getting him a date has contributed to the internal BDD narrative that he is “ugly”.

What is reinforcing my confusion is I am on these dating websites, and I am not even getting glances. So, it really reinforces to me this belief systems that I have had for 50 years about my body, that I am ugly or that I am unattractive or that I am cursed or something.

While on the one hand Ted has internalized this negative narrative about himself, when he does receive positive attention or feedback, he struggles to internalize it. “It’s like “why are you being nice to me?” I don’t deserve it. I still have this complex where I deserve the abuse”. This highlights a complex relationship between Ted’s BDD and trauma history and reflects the double bind of wanting romantic connection while rejecting what does become available.

Anthony’s negative self-perception is reinforced by drawing comparisons between himself and other gay men in gay spaces (APA, 2013). Despite receiving positive feedback and there being potential connection, Anthony rejects advances because of the strength of the narrative that he is not good enough.

I thought I was an outcast even still today like if I go to gay bars you know, like a lot of guys come up to me, been told I am attractive, but I don’t feel that way and. I still walk into those bars and still feel average compared to other men… so often time I feel like I am subpar and average compared to others, and not liking how I look compared to others.

Sexual

Just as some participants are in the double bind of wanting romantic connection yet rejecting it, there are participants who want sexual connection yet find themselves rejecting it due to the ways in which sexual connections can trigger BDD symptoms. Ted, whose experience is also reflected above in the romance subtheme, stated, “My goal for 5 years is to have a third date with somebody…”. However, the experience of rejection on the dating websites, and the internal narrative that the rejection is due to his appearance has led him to conclude, “I am to the point now where I don’t even want sex. I miss touch. Yet it has been so long that I am almost afraid of touch. It is a double-edged sword.” The double bind here stems from Ted’s indication of interest in dating but that on the one hand he wants touch, while on the other there is fear surrounding it.

Jay experiences the double bind in that he wants and has sex, however rejects an expansive view of what sex could be like for him due to his BDD. He believes it would be emotionally painful for him, because of the way BDD influences his perception of his body and its desirability, to engage in sex acts outside of his preferred, restricted repertoire. Jay’s preferences in his sexual relationships have led to relational discord and interfered with his ability to maintain connections.

I never, like top or bottom and do both and I strictly top because I didn’t want him to see me from behind because my butt is large. It led to arguments because of how ridiculous it was… being in love and having restriction was unfortunate.

For these next two participants, Fades and Ross, the double bind manifests in the form of helting potential sexual encounters, despite initially wanting to get close, due to concerns about how their bodies will be received. A part of Fades’ BDD narrative is focused on the size of his penis and how it may be perceived by potential sexual partners. He states:

Whenever I am getting close to someone physically for example kissing or touching my mind will start wandering to how will they react when they see how small I am which off course leads to me pushing away or avoiding.

Despite initially engaging in physical closeness with others, wishing to distance from the discomfort of his BDD narrative about his penis and how others may react leads to an ultimate rejection of that which he desired. He goes on to say, “I would always avoid getting physically close to anyone, even partners, unless it was pretty much necessary,” which highlights how the discomfort is not mitigated by the closeness of the relationship. Similarly, Ross’ hyperawareness of his perceptions of his body and assumptions about how other people respond has led to fear surrounding, and rejection of, physical intimacy.

Like, never comfortable with your clothes off, never feeling attractive not being able to date. Like I was with a guy one time and we had a couple of drinks and he grabbed my lower back where I have a roll and I tensed up and said “don’t touch me there” and I walked away and shut down the conversation. And he probably meant it in a good way like I wanna go home with you and so it was a missed opportunity where I closed off… I am afraid of dating and now that we are talking about it, it is probably tied. I don’t go home with guys often, probably tied.

Theme #3 - caught between cultural expectations and desires for self

The third theme this paper will explore is a double bind experienced by gay men with BDD and how influences from both dominant media and cultural expectations within the gay community impact them. The demands made at both levels of influence create a structure in which participants reported sensing a choice had to be made between meeting specific, often unattainable, appearance expectations and fitting in, or being their authentic self.

TV/internet/dominant media

Five participants spoke to the impact of media and/or social media messaging about how gay men are “supposed” to look and behave. For these participants, expectations set forth by the dominant media fed into appearance preoccupation and compulsive behaviors, such as comparing the self to others; both of which are symptoms of BDD (DSM-5). The double bind here is that because representative media is so limited, to choose to disengage from the media, and potentially help soothe the BDD symptoms, is disruptive to connection with the community culture. For example, this first participant, Lawrence, discusses the rejection that can come simultaneously from larger society and from the gay community if one does not meet appearance expectations related to gender.

…Does that mean that if you look pretty, or some aspect of attractive, does that make you not a man? Because “Men are handsome, and girls are pretty” to quote messages from our society. And from a gay standpoint you develop some aspects of self-hatred that you may be holding the movement back by falling into stereotypes by wearing makeup or skinny jeans, which were perceived as “girl” jeans. How far is too far before you looked weak? That aspect is really challenging.

For Carlos, media creates a double bind in that he can find validation for his gay identity, while he simultaneously experiences identity invalidation and erasure as a Latino gay man.

Once I came out, I started looking for gay media and I think that is when things started to go sour for me. It was this idea that. I watched Queer as Folk and it has a lot of sex, drugs and indulgence and I was around 17/16 and I was thinking that this was the kind of world I needed to be a part of and I didn’t like that and created animosity towards the gay community because I didn’t look like those blue-eyed blonde boys that everyone was validating. I am Hispanic and skinny with a long nose and became more hyper aware of what I am not, which was not what they are showing… But at the same time, it’s the same people I am fighting for rights for. If it wasn’t for what is on TV or in the media, I wouldn’t be telling anyone that I was gay. It’s complicated. Media helped me made sense of my identity.

Matías also cites the portrayal in media of gay men as white and blonde as a form of invalidation in his identity. He is not able to reach out for media to validate his gay identity without being confronted by the erasure of Latino representation and, therefore, an invalidation of his intersectional identities.

Its… I can’t see myself in a positive way for very long because I don’t believe… It starts from advertising to casting in movies…who is portraying the community? It is constantly getting slammed no matter what. I have never been ideal, and I am still not. I felt that way initially because I am not a white male who is blonde, but they went from that to very quickly to body shaming myself.

These next two participants, Jay and Ross, both cite social media as a source of pain and confusion. Here Jay describes a double binding Twitter culture in which a person can post either a photo of feeling good about themself or a photo showing some insecurity and either way be scrutinized. Public body shame and public body love can both lead to rejection.

Like now on Twitter there is this thing where guys post a selfies and say “I am proud of my body” and it is guys with amazing abs and there are these groups that are tearing them down when the guy says “I am a little flabby and people will respond with “how dare you?” and they will be offended and shun the guy who probably has had body issues and is finally proud of himself with what he sees and he doesn’t see the abs everyone else sees.

For Ross, social media creates both a sense of community and exacerbates the negative feelings about his body upheld by his BDD. He feels pressure to conform to the ideals put forward on social media in order to access a sense of community belonging, however, to relieve the pressure on himself and BDD activation, he would risk isolation from the community that is otherwise helpful.

Probably social media. I feel like that really heightens it and every time I log on. I follow male influencers and models and I follow them a lot because they post tips and I get workout tips… And I think it feeds the BDD because if I didn’t have social media, I wouldn’t have those diets, workouts etc. but if I also didn’t have social media, I would have those pressures. So, I think that is a good intersection of my own self-hatred. It’s a double-edged sword. Brings up this never enough feeling again and again. They are telling me what to do and I still don’t look like that. What am I doing wrong? I compare and get jealous and angry.

Other gay peers (community at large)

Seven participants spoke to the impact of the gay community at large on their sense of self and the choices they have had to make about their involvement with the community. For Ted, the double bind takes the form of a dissonance between "what a gay man is" in the participant’s mind, based on messaging from community and media, and his own experience of himself and how he wants to show up in the world.

I don’t know what being a gay man is. I guess it is being pretty? A feminine? I’m not that. I’m a 6’5 guy with a beard. I will never be one of them. For me the dysmorphia is because of that, the bear community helps that. It is a rebellion of we are not twinks, we are not them, we are not all Will & Grace. To me the dysmorphia is the exercise queens.

For both the above participant and the following participant, John, their experiences of who and what is idolized within the gay community has led them to reject aspects of community as a means for self-preservation.

It is more than just being with people, there are parties with people’s shirts off and there is nowhere in hell I would go there. I naturally shut down. I get petty to these men who look like these gods because of what they get…I avoid places, like gay spaces, like the plague.

The next two participants, Carlos and Anthony, reported similar experiences in which the gay community is at once a place of refuge from heterosexist societal rejection, and yet accessing that refuge brings an awareness that there are standards one must meet to be validated and accepted within it. Carols speaks to the all-consuming nature of the initial sense of validation that comes from being in a space that does not question your legitimacy as a gay man.

That community will welcome but if you don’t watch out it will consume you. I mean it makes sense, most gay men do seek validation because they grow up to believe that they are going to burn in hell or that they don’t have rights, that was always being debated by everyone and that does something to your psyche and so this community is very appealing going into it, wanting validation and starting to pull into everyone and be perfect for them. It is easy to be wanted to be perfect so you will fall into that.

Below, Anthony notes that his experience of BDD is tied into his sexual identity in that community messaging reinforced a specific idea of what he needed to look like to meet the “ideal” and be accepted.

I would say it was very much related to my sexual identity um because I have this idea in my head of this is what I thought like I needed to look like and I felt like I didn’t look that way and I just tried my hardest to get back into this box of what is this ideal within the gay community.

Matías and Jay both spoke to the confusing nature of the culture. They each highlight ways in which men within the community can perpetuate these harmful ideals, despite recognizing the counterproductivity of it. Matías’ explains below how intraminority stress can play out among gay men.

…What we are saying is not directed at others, it’s directed at men who I want to want me and then that reinforces everything negative that I feel about myself… If I were at a bar with friend and there was an attractive person who walked in and I disclosed my interest, one of the venomous ones would say “really, you’re a little fat.” It’s just cruel. There’s this toxicity in the gay male community that we are allowed to put ourselves down. But that makes sense because it is how we are trained when we are younger to treat gay people.

Jay also speaks to the way intraminority stress is perpetuated. There is a level of awareness within the community that the ideals put forth and the way those standards are upheld is harmful, and yet the pattern of behavior is upheld.

Having to be this idea of a man having perfect abs and curves which is all pretty ridiculous no one actually agrees. We are all dealing with the same crap yet socially we still do it and talk about diets. Yeah, I don’t think my identity has helped. These messages from gay male culture are impacting… I want to be proud to be a part of this community, but it is actually hurting me.

This last participant, Lawrence, speaks directly to the double bind by naming, “damned if you do and damned if you don’t.” His perspective is that whichever way you turn, there is someone there to undercut the direction you would like to move in.

Being a gay man with BDD means you’re not only never good enough but you’re also damned if you do and damned if you don’t. At any point where you turn someone is upset with what you’re doing which reinforces the negative symptoms.

Discussion

The present study utilized a phenomenological approach to explore the double binds experienced by gay men with Body Dysmorphic Disorder (BDD) and what role, if any, the gay community may play in imposing such double binding structures on gay men’s relationships with their bodies. To the knowledge of the authors, this is the second study to evaluate the specific impact BDD can have on the lives of gay men with BDD. Participants in this study reported a number of ways their BDD symptoms lead to crossroads of impossible choices between different types of pain (Double Bind citation). Data from the participant interviews reflect three particularly salient double binding themes: My Armor is My Spotlight, Wanting Intimacy but Rejecting It, and Caught Between Cultural Expectations and Desires for Self.

Each of the themes reflect a set of choices faced by the participants in which neither option can be categorized as “good”, but rather elicit a sense that “no matter what I do I can’t win” (Bateson et al. 1957; Watzlawick, 1963). Each double bind theme apparent in the data places at odds the participants relationship to their body, through the lens of BDD, and their interactions and relationships with other people. While this is the first exploration of double binds within the population of gay men with BDD, it is not the first to examine how sociopolitical contexts may impact body image in minoritized populations (Yokoyama, 2008). This present study reaffirms Yokoyama’s (2008) discussion of sociocultural influence on Asian American women’s body image and disordered eating by offering additional support to the necessity of accounting for identity in the assessment and treatment of body image concerns.

This study adds to the literature by presenting qualitative data to support taking an intersectional approach and by displaying the influence of differing contextual layers—from the individual, one-to-one relational context, up to the community and cultural context.

At the individual one-to-one level, seven participants reported wanting romantic or sexual intimacy, with two participants falling into both categories; however, when the opportunity for intimacy became available, the BDD influenced self-perception would interfere, leading the participant to reject the opportunity (Oshana et al., 2020). The second double bind can operate at both the one-to-one and at the community level. Here, six participants discussed the double bind of My Armor is My Spotlight. Four reported the utilization of adornment, such as makeup and clothing, four reported utilizing methods of bodily alteration through a fixation on weight and/or Jaye at the gym, while two experienced both categories, to attempt to manage their self-perception, as a form of self-protection (Fabris & Longobardi, 2020). However, these attempts to create a sense of safety from the intrapsychic experience, BDD symptoms ultimately led to increased attention by others on the very part of themself they were attempting to alter or conceal. Thus, the participants are stuck in the double bind.

At the community level, seven participants indicated a tension between their sense of self and their identity as a gay man as it intersects with the gay community at large. They described pressure both from dominant media about what it means to be an attractive gay man and from the community at large to conform to particular appearance standards in order to feel welcome and desirable. This messaging created a double bind for seven participants in which they recognized a choice between community engagement and self-acceptance. These reported experiences of distress fostered by the community itself are consistent with intraminority stress theory (Pachankis et al., 2020). The participants viewed the community as a source of pain and/or confusion about expectations for their body, thus contributing to their BDD symptoms. This finding is consistent with a study by Ahmadpanah et al. (2019) which found an association between BDD and sociocultural attitudes towards appearance among Iranian young adults. Additionally, the study highlighted the likelihood of social feedback and the pursuit of a mate as moderating factors (Ahmadpanah et al. 2019).

A strength of this study is the participation of racial minority men (40%). Latino participants spoke to the cultural messaging in the media and within the gay community that to be desirable means to have blonde hair, blue eyes, and maintain a muscular build. The overrepresentation of white men contributed to the perception that their own bodies could not measure up. One participant spoke directly to how the erasure of men who look like him evolved into him body shaming himself. This speaks to the importance of considering intersectionality when considering the potential relationship between BDD and intraminority stress (Kim & Allen, 2023). While this is a key consideration, more research is needed to explore differences in the experience of BDD by gay men who belong to a racial minority group compared to white men.

Limitations

The limitations on the present study include purposive sampling in the context of a qualitative study. The sample size is small at 10 participants however there is no specific guideline within Hermeneutic Phenomenological research determining sample size needs (van Mannen, 1997). Saturation of the data is, however, a common method for identifying themes within the data. While it is a strength of this study that 40% of the participants are LatinX, the sample size is still small and the experiences of the white and Latinx participants cannot be generalized beyond this specific participant group. Further research is needed to understand the impacts of racial and ethnic differences on gay men with BDD. Further research is also needed to generate expanded information about the experiences of transgender men and how trans identity intersects with body image and BDD. Furthermore, additional research with a larger sample size with greater diversity is needed to draw conclusions about the larger population.

Clinical implications

There are a few important clinical takeaways offered for therapists working with gay men with BDD. First, the findings of this study are consistent with previous research suggesting that sociocultural factors may have an impact on gay men’s relationship to their body (Brennan et al., 2013; Frederick & Essayli, 2016; He et al., 2020: Pachankis et al., 2020). Furthermore, this study highlights many ways in which gay men with BDD are confronted by painful double binds as they negotiate their identity, their relationships, and their experience with BDD. It is important for clinicians to understand that, while group membership can be an important protective factor for gay men in some ways (Lyons & Heywood, 2016; Shilo et al., 2015), social factors such as group norms, appearance standards, and media messaging about what it means to be a desirable gay man can negatively influence gay men’s relationship to their bodies and to one another. Furthermore, these barriers to self and interpersonal intimacy can either foster or exacerbate BDD (Morgan-Sowada & Gamboni, 2021). However, therapists should avoid generalizing these findings to all of their gay may clients who struggle with BDD. Clinicians should instead remain open and curious to ways in which their clients may feel trapped and whether the experiences represented in this data are congruent with their individual experiences.

Another key clinical implication pertains to all, and especially couple and sex therapists. When working with gay male clients with BDD, clinicians should explore with their clients the ways in which sex/intimacy and BDD symptoms may influence one another. If a client reports constraints to their ability to form and/or maintain physical or emotional intimacy with either current or desired future partners, the clinician should work with the client to identify and address underlying fear and anxiety surrounding the internal narratives about pursuing intimacy. Furthermore, the clinician should be cognizant of the socio-cultural layers influencing gay culture, dating, and perceptions of desirability and the ways in which these macro factors may be influencing an individual desire to put on armor, reject otherwise wanted intimacy, and/or to choose between community or self. Calling attention to these larger factors of influence may be helpful in relieving a sense of individual responsibility or self-blame for symptoms.

Future directions

Future research is needed to provide clinicians with clearer treatment strategies for working with gay men who have been diagnosed with BDD. Additionally, research will assist therapists who work with men navigating challenging relationships with both their bodies as well as with the gay community at large. Research in the future should also address additional layers of complexity for gay men with BDD who struggle to see themselves represented in gay culture, such as trans men, racial and ethnic minorities, and men with disabilities. Additionally, research investigating methods of intervention at the couple and family level are needed to address the reported barriers to intimacy and relational satisfaction.

Conclusion

In conclusion, this study has presented an in-depth look into the experiences of 10 gay men with BDD and uncovered a set of double binds (My Armor is my Spotlight, Wanting Intimacy but Rejecting It, & Caught Between Cultural Expectations and Desires for Self) impacting the participants lived experiences. These double binds make it challenging for these participants to achieve a sense of safety within their own skin and/or within the gay community. While the data suggests intraminority stress may be a factor influencing the experiences of the participants, the authors do not wish to imply that being gay or involved in the gay community is a cause of BDD. Sociocultural values must be accounted for and evaluated for their influence on the way power dynamics and determinations of desirability are enacted both broadly, within the gay community, and on a one-to-one relational basis. Clinical implications and future directions for research are presented for those working with this population.

Disclosure statement

The authors declare that there is no conflict of interest.

Additional information

Notes on contributors

Casey Gamboni

Casey Gamboni is a licensed marriage and family therapist who received his PhD in Couple and Family Therapy from the University of Iowa in 2019. Dr. Gamboni is currently teaching and supervisory faculty at The Family Institute at Northwestern University and a director at Pinnacle Counseling, a private practice in the Chicago, IL area. His research and clinical specialties are sibling relationships, sexual minority populations, and emerging adults. He is currently publishing and presenting on topics focusing on the gay male population; exploring topics such as body dysmorphic disorder, social anxiety, and the significance siblings play in the coming out process.

Elise Parisian

Elise Parisian, is a recent graduate of The Family Institute at Northwestern University’s Marriage and Family Therapy program. Parisian is currently a clinical associate at a small private practice and is interested in the intersections of LGBTQIA + identities, media/culture, and relationships.

Heather Morgan-Sowada

Heather Morgan-Sowada is an Assistant Professor at Mount Mercy University within the graduate department of Marriage and Family Therapy. She is a licensed Marriage and Family Therapists who completed her Ph.D. in Couple and Family Therapy the spring of 2018 from the University of Iowa. Her master’s degree is in Marriage and Family Therapy from Mount Mercy University, which was completed in spring of 2012. Dr. Morgan-Sowada’s research and clinical specializations are in Body Dysmorphic Disorder, sexual/gender minority individuals, and the intersections of those two topics. Dr. Morgan-Sowada and colleagues were recently published in the Journal of Marriage and Family Therapy for their paper entitled: “It’s splendid once you grow into it:” Client experiences of relational teletherapy in the era of COVID-19 (Mar-2021).