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Body Dysmorphic Disorder and Muscle Dysmorphic Disorder in LGBTQ+ Teens

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT
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How Body Image Can Impact Mental Health and Self-Esteem In LGBTQI+ Teens

The world our teens live in today is filled with images of perfect people with perfect, tan, healthy bodies enjoying what adults a generation ago would have called the lifestyles of the rich and famous. Although everyone knows most people that the people who post these images – mostly viewed on online social media platforms so ubiquitous we don’t need to name – are, for the most part, not actually rich and famous, that doesn’t matter.

What matters is how they look in each post, each video, each streaming story, or each clever ten-second video clip.

Appearance, it appears, is everything.

We know from recent data published by Common Sense Media, along with data leaked from a former Facebook employee, that the near-constant comparing inherent in scrolling through social media feeds – meaning the person scrolling compares themselves to the images they see – can have a negative impact on the mental health of specific segments of the adolescent population. Specifically, teenage girls with a history of low-self esteem or a previously diagnosed mood or anxiety disorder are at risk of exacerbating their symptoms by continuously comparing themselves to the images of the perfect, healthy, happy, and fit people they see online.

The carefully staged perfection our teens see is not real. Taken to extremes, it’s clearly unhealthy. But the kind of perfection we want to talk about here did not start with social media. To be more accurate, the ideal of perfection we discuss in this article was well-documented long before the advent of social media.

What we’re talking about is what can happen when an individual has an idea of what perfection should be, but when they look at their own body, all they see is imperfection – no matter what their body looks like, objectively.

Body Image, Body Perception, and Body Image Disorders in Adolescents

What can happen when there’s a disconnect between the way a person actually looks – according to objective metrics – and how they perceive how they look is that a host of mental health disorders can develop. Most people know about eating disorders such as anorexia, wherein a person always believes they look larger than their measured size or weight indicates.

This article is about two different, but related disorders – body dysmorphic disorder (BDD) and muscle dysmorphic disorder or muscle dysmorphia (MD) – and how they manifest in LGBTQI+ youth and teens.

We’ll start with body dysmorphic disorder.

Body Dysmorphic Disorder: A Clinical Definition

According to the Diagnostic and Statistical Manual of Mental Disorders – Volume 5 (DSM-V), the go-to diagnostic manual for mental health professionals, an individual meets the criteria for BDD when they display the following symptoms:

1. Preoccupation with Appearance:
  • They display a nontypical preoccupation with one or more nonexistent or barely noticeable imperfections in their physical appearance. To others, the perceived flaw looks normal. To meet clinical criteria, preoccupation with the imperfection is present for at least an hour a day.
2. Repetitive Behaviors Related to Appearance:
  • They engage in repetitive, compulsive behaviors related to their preoccupation. Compulsive behaviors may include:
    • Checking the mirror constantly
    • Grooming excessively
    • Picking at skin
    • Seeking reassurance from others constantly
    • Constantly comparing their appearance with others
3. Clinical Significance:
  • The preoccupation causes significant emotional distress or impairment at work, with peers in social situations, or at school.
    • This criterion helps define the disorder as something that requires professional treatment and support. This differentiates it from typical adolescent concerns about appearance that do not meet a clinical threshold and therefore do not require treatment.
4. Absence of an Eating Disorder:
  • If the preoccupation with appearance is weight-related, the assessing clinician must rule out the possibility that an eating disorder, rather than BDD, is the primary disorder causing clinical impairment.
  • Preoccupation with weight in a person of typical weight may be a symptom of BDD. It is possible for a person to have an eating disorder and BDD at the same time.

There are two more factors clinicians consider when diagnosing BDD:

5. Muscle Dysphoria (MD):

  • Muscle dysphoria is a subtype of BDD. This type involves the belief that their physical build is not sufficiently muscular. People with the muscle dysmorphia subtype show higher rates of suicidal behavior, alcohol and drug use disorders (AUD/SUD), and lower overall wellbeing, compared to people with typical BDD.

6. Level of Insight:

  • When diagnosing BDD or MD, the clinician determines the level at which the individual being diagnosed believes their perceptions of their physical characteristics are objectively true. These levels of insight include:
    • Good or fair insight: the person understands their perceptions probably don’t match reality.
    • Poor insight: the person accepts their perceptions may not match reality, but believes their perceptions over reality anyway
    • Absent insight/delusional beliefs: the person does not accept the idea their perceptions do not match reality

That’s what BDD is, according to the latest diagnostic criteria applied by mental health professionals. Next, we’ll discuss why BDD is a concern among adults who work with LGBTQI+ teens. Then we’ll discuss the prevalence of BDD and MDD in the general population and share statistics specific to the LGBTQI+ community.

Body Dysmorphic Disorder and LGBTQI+ Teens

Although there is not a great deal of research on the prevalence of BDD/MD in LGBTQI+ teens, one reason mental health professionals are concerned about BDD/MD in gay, transgender, and/or nonbinary teens is the stigma and scrutiny they experience from judgmental, non-accepting peers and family members. Non-supportive community members often judge their appearance and the external ways in which they manifest their gender and sexual identities. LGBTQI+ teens often internalize these judgments, which can increase their risk of developing a wide range of mental health disorders, including BDD and MD.

Now let’s look at the numbers we do have.

Body Dysmorphic Disorder: The Latest Statistics

Reports show the presence BDD in:

  • About 2.5% of the general population

BDD can have a significant impact on daily life. Data for adults shows that among those with BDD:

  • 36% miss work because of BDD
  • 11% dropout of school because of BDD
  • 40% received psychiatric care for BDD
  • 80% report suicidal ideation
  • 25% attempt suicide

Data on adolescents from the same reports show adolescents with BDD experience:

  • Disruptive, time-consuming preoccupation with appearance
  • Disruptive, time-consuming appearance-related compulsive behaviors

Additional studies on adolescents with BDD – one here and one here – showed:

  • 94% reported social impairment
  • 94% reported hiding their perceived imperfections with clothing
  • 87% reported negatively comparing themselves with others
  • 85% reported academic impairment
  • 85% reported constant mirror checking
  • 61% were preoccupied with their skin
  • 55% were preoccupied with their hair
  • 38% reported psychiatric hospitalization
  • 21% reported suicide a suicide attempt
  • 18% dropped out of elementary school or high school because of BDD

Those are the statistics for the general adolescent population. Unfortunately, there is no available data on the specific prevalence of BDD/MD among LGBTQI+ teens. There are, however, studies available on the prevalence of BDD/MD in the adult LGBTQI+ population.

We’ll look at that data now.

Body Dysmorphic Disorder in the LGBTQI Community

We’ll start this section with a quote from a study on BDD and MD among LGBTQI+ adults. The concept described here explains why – despite the lack of research and prevalence rates of BDD and MD on LGBTQI+ teens – it’s important for parents and mental health professionals who work with LGBTQI+ teens to understand and monitor for BDD and MD.

The concept is known as minority stress theory:

“Minority stress theory, which suggests that stigma, prejudice, and discrimination experienced by sexual minorities may lead to health disparities, may be an important consideration with regard to the experience of MD symptoms in sexual minority individuals. For example, individuals experiencing minority stress may experience psychological (e.g., depressive or anxious symptoms, low self-esteem) or behavioral disturbances (e.g., pathological exercise, eating pathology) that could contribute to elevated risk for muscularity-oriented psychopathology, including MD.

We apply identical logic to the potential for BDD and MD in the adolescent population. The cumulative external and internal stressors associated with identifying as LGBTQI+ during adolescence create a layer of risk for the mental health disorders that can lead to BDD and BD that non-LGBTQI+ teens do not experience. With that in mind, let’s look at the data for adult LGBTQI+ men and women – according to this study and this report – with the understanding that we can logically extrapolate how this data may apply to LGBTQI+ Teens.

Prevalence Of BDD in Sexual Minority Men and Women

  • 12.5% of gay men met criteria for MDD
    • 32% report body dissatisfaction
  • 7.7% of sexual minority women a diagnosis of MDD
    • 35% report body dissatisfaction
  • Among LGBTQI+ adults, body dissatisfaction is associated with:
  • Higher rates of depressive symptoms
  • Higher rates of mental health disorders
  • Increased rates of self-perceived overweight, regardless of actual weight
  • Greater body dissatisfaction, compared to non-LGBTQI+ peers

When we understand the implications of minority stress theory, apply them to the adolescent LGBTQI+ adolescent population, consider their increased vulnerability to mental health disorders, then factor in a baseline adolescent preoccupation with appearance and body image, we come to the logical conclusion that BDD and MD are two disorders to which LGBTQI+ teens are particularly vulnerable.

What Parents Can Do

If your teen meets the diagnostic criteria listed above for BDD/MD – whether they’re a member of the LGBTQI+ community or not – the most important thing to do is arrange a full psychiatric evaluation with a licensed mental health professional. There are therapists, inpatient treatment centers, outpatient treatment centers, and support groups designed to meet the needs of the adolescent LGBTQI+ community.

An early diagnosis can help your teen learn the skills they need to manage the symptoms of BDD/MD and live a full, productive life. For help finding support for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.

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We are an expert team of behavioral health professionals who are united in our commitment to adolescent recovery and well-being.

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