Podcast: The Silent Battle: Men, Body Image, and Mental Health

Jenn talks to Dr. Roberto Olivardia about the short- and long-term effects that negative self-image have on those that identify as men. Roberto discusses the impact of unaddressed image issues over a lifetime and shares ways to encourage body positivity in male populations.

Roberto Olivardia, PhD, has been treating patients for the last 20 years since his internship at McLean Hospital. He runs a private practice in Lexington, Massachusetts, where he specializes in the treatment of body dysmorphic disorder, obsessive compulsive disorder, ADD/ADHD, skin picking disorder, and males with eating disorders. Dr. Olivardia also treats patients with other anxiety and mood disorders.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi folks. Good morning, good afternoon, good evening. Wherever you are joining us from in this beautiful world, thanks for joining to talk all about the silent battle between men, mental health, and body image.

I’m Jenn Kearney, and I am joined today by the ever-delightful Dr. Roberto Olivardia. For those who identify as male, body image issues really aren’t often discussed, yet still impact a major part of the population.

I know I can think off the top of my head about several body positivity campaigns that exist for women, but honestly can’t think of any that are geared directly toward men.

But I do know that things like bulking up and being ripped, muscular, Hollywood superheroes are pretty rampant, because that’s what comes to mind when I think about body image for men, and I can only imagine that if a man isn’t fitting what society has deemed quote, that ideal image, it has to have short and long-term implications to self-esteem, mental health, their relationships, and so on.

So, I’m super excited because Roberto is actually an expert in this arena, and he’s with me here, he’s with me today to talk about the impact of unaddressed image issues over a lifetime in men, how we can encourage body positivity, and almost as importantly, how we can address stigma, because if we’re not talking about it, when can we start?

So if you are unfamiliar with Dr. Olivardia, you are in for what I mean quite literally the most pleasant surprise, because he is one of the friendliest people I’ve ever encountered, and his enthusiasm for talking about mental health is nearly unparalleled. It’s up there with me, but it’s practically unparalleled.

He’s been treating patients for the last 20 years since his internship at McLean, and he runs a private practice in Lexington, Massachusetts, so he specializes in the treatment of body dysmorphic disorder, OCD, ADD, ADHD, skin picking disorder, males with eating disorders, and other anxiety and mood disorders, so he’s got a lot of information up here.

So Roberto, I’m so psyched for you to join me today, so thank you so much for joining yet again to talk about another mental health topic.

Roberto: My pleasure.

Jenn: Body image in men isn’t really discussed all that often, but you know so much about it, so how did you actually get there, and what made you want to become a specialist?

Roberto: So first it’s always great chatting with you, Jenn, and for those of you who are watching this. So my journey in this actually started as an undergraduate.

I did my undergraduate studies at Tufts University, and I took a class on eating disorders, and at that point, it wasn’t a huge interest of mine. It fit my schedule, I thought this would be interesting, the intersection of a psychiatric diagnosis with culture was interesting.

And as a final paper for that course, I thought oh well why don’t I write about men and eating disorders? And I had actually known a couple men in college who had eating disorders, who could not find any help.

I remember going, we went through, this is pre-internet, the yellow pages, and trying to find resources, and a lot of the places only accepted women, and there were certainly no support groups or anything for men, so they were untreated.

So I went into the research literature, and I thought wow, there’s a lot of gaps here, and there isn’t really a lot talked about, and then that motivated me to write a senior honor’s thesis at Tufts, and I picked up the phone and I cold called Dr. Harrison Pope, who’s a psychiatrist at McLean, who had written a case study about men and eating disorders, and I thought maybe I can pick this guy’s brain.

And literally, it was like the beginning of a wonderful relationship that continues today. He invited me to McLean the next day. I had no idea where Belmont Mass was at the time. My world was much smaller than it is now.

And we did the study, and I had placed ads in almost every college in Massachusetts for men with eating disorders, and thinking let’s hope we get people, and we got a lot of people. I mean I had men, even on my answering machine tape at the time leaving messages of I can’t believe you’re studying this, I thought I was the only one.

And then I realized wow, we have to do more with this, and my enthusiasm a lot in this world of psychology, psychiatry, is really trying to fill those gaps. Who are we not meeting the needs of? Who’s underserved?

And it just developed into working with men and eating disorders, and then we’ve also done research on men who compulsively lift weights, and we’ll talk about something called muscle dysmorphia, and it just really exploded into this interest, and something I really love doing, clinically as well as research.

Jenn: So you’ve been studying this for a couple decades, so you’re going to know this almost better than anybody, I would say, except for Harrison Pope.

How prevalent are body image issues in those that identify as men, and I would say almost as importantly, why aren’t we talking about them? It’s obvious that there’s a need to talk about it, so what’s the hold up?

Roberto: Yeah, so it’s much more common than people think. I mean, one of the things that we always, I guess to preface that question, is understanding that how we’re identifying this, less than one percent of research in the field of eating disorders is devoted to men.

So there isn’t a lot of outreach to even adequately study the full prevalence of it. I can tell you that in studies that I have done where I’ve always drawn from men from the community, and interestingly, that thesis that I did at Tufts, unbeknownst to Dr. Pope and I, that was the first controlled study of men and eating disorders.

Prior to that it was only drawing, that drew men from a community sample. Prior to that, any of the studies had drawn men from eating disorders from clinical samples, men who were already in treatment.

Most of the men that elected to do that study were not in treatment, and all of them said, the ones that didn’t, I mean the majority of them that were not in treatment said that they had a lot of shame, and there was a tremendous amount of stigma.

So there are far more men, I mean even men that I treat, I am sometimes the only person that they have disclosed that they struggle with body image issues and an eating disorder. I mean, some of these men are married and have very close relationships, but they just don’t know how to talk about it.

So when we look at something like eating disorders, for example, that recent studies actually show Dr. James Hudson who’s a psychiatrist at McLean did a wonderful study in looking at the prevalence of eating disorders in different genders, and he found in his study that one in four individuals with an eating disorder are male.

That’s much higher than people think. What’s noteworthy though, is one in 20 eating disorder patients are male. So you have a lot more men who are not seeking treatment who are struggling with this.

When we look at something like body dysmorphic disorder, as we talked about in the webinar we did on BDD, that it’s actually a pretty, it’s a 50-50 gender distribution, that just as many men as women have body dysmorphic disorder, and that’s anywhere from one to three million men. With eating disorders, it’s about 10 to 15 million men have eating disorders.

Then when we broaden it to body image issues, now we really see a different landscape. Recent studies, particularly ones that have looked at social media, with adolescents, find that body image related issues are probably more equal than we think.

Now, that doesn’t get publicized. Like we don’t hear boys, for example. It’s not cool for boys to be like oh I think I look too fat, or I think this. But they have those issues. Now, how they talk about it could be different.

But studies show that boys actually are pretty equal to girls in what we call subclinical eating disorders, which are kind of disordered eating patterns that might not meet the DSM criterion.

But studies have shown even longitudinally, in the 1970s when they looked at body dissatisfaction between men and women, that I think at that point it was maybe 10% of men reported that they were dissatisfied with their bodies. In the 80s, you saw that double. In the 90s, you saw that in the 30% range.

Now you’re seeing it in the 50% range. So it’s much more prevalent, but we, there’s still so much shame, so much stigma, and lack of identification, and lack of outreach, really, that give men voices.

I think even when I did that first study when men were saying wow, the fact that you’re even doing this study makes me want to talk about it because it means that clearly other people are struggling with this.

Jenn: So I know when we talk about body image issues, it’s kind of like a giant, to me, it’s like a giant word cloud, because there’s a bunch of conditions that can actually fall under there, and I know you’ve mentioned eating disorders, body dysmorphic disorder.

Are there other conditions? I know that you had mentioned men who weight light almost excessively. Are there other conditions that we should also be addressing under this body image umbrella?

Roberto: Yeah, so under these different manifestations, you have eating disorders such as anorexia, bulimia nervosa, binge eating disorder, which actually, the binge eating disorder in particular that studies show a fairly equal distribution of gender.

You have body dysmorphic disorder, and actually a subtype of BDD is something that Dr. Pope and I actually coined the phrase muscle dysmorphia, and this was when we started doing research, looking at men who, interestingly, a lot of them had a history of anorexia nervosa as boys.

And then in some ways, they recovered from anorexia, but the pendulum swung in the other direction, and they were just as obsessed about food, just as obsessed about calories, except they weren’t looking to be thin, they wanted to really be super muscular.

So this is, in earlier papers Dr. Pope would refer to it as reverse anorexia, but because this isn’t an eating disorder per se, we used the phrase muscle dysmorphia.

And these are men who typically can be very muscular, by objective measures, and they see themselves as looking too small, or they fear that they’re going to get scrawny and small, so they compulsively lift weights, up to 50% of them use anabolic steroids.

They’re obsessed with the food that they eat, but more because they don’t want to have any food that will, in their minds, take away from their muscle. And this can really impair their lives, and impair their functioning.

And that’s been something that has really gained sort of a lot more understanding, enough that muscle dysmorphia is now in the DSM as sort of a subtype of body dysmorphic disorder.

Anabolic steroid use is also another area that we think of anabolic steroids as being these performance-enhancing substances, which they can be, I mean certainly we see this in athletes.

However, Jenn, the primary indicator, or the primary reason that the majority of people use steroids are actually for body image related purposes. And studies show that as many as six to nine percent of high school boys have already started using steroids.

And again, this is something that’s vastly under-reported because of course, who’s going to be admitting to that? I’ve worked with boys as young as 14 who have already done cycles of steroids.

They’re so much more accessible than they ever have been. But if you imagine, here’s a substance that will guarantee that you can gain a certain level of muscle. However, it has a whole host of physical and psychological adverse consequences to it.

But it’s almost like the male diet pills, so to speak. Like if there’s this pill that’s like here, you can shed 20 pounds of weight like that, but for a lot of boys and men, it’s not about, even the boys and men that I work with who struggle with anorexia, most of them aren’t really looking to be skinny.

They want to be lean. So the meaning of it is a little bit different for them than what we would see with women.

Jenn: I’m curious about, can you talk about the harmfulness of steroids and performance-enhancing drug usage? One of the things that I’ve always found really fascinating is that there’s so many jokes that perpetuate those conversations about bro culture, in air quotes.

So that it’s almost like it seems like it’s trying to become normative to be using steroids, or juicing, or bulking up, or whatever language the kids are using these days.

But I can’t actually imagine that any of that is really helpful in terms of either accepting what their body is like naturally, or them considering reduction of using drugs, or even trying to get help for drug usage.

Roberto: Absolutely. So anabolic steroid use is basically the synthetic derivatives of testosterone, and testosterone increases muscle mass.

So when you’re working with someone who’s saying hey, these things really work, they’re often going to be correct, in that they’re going to build the sort of level of muscle.

However, when you, and there are some people who are prescribed testosterone for low testosterone, that’s very different than what I’m talking about. And I’m not talking about anti-inflammatory steroids.

I’m talking about anabolic androgenic steroids that are meant to create muscle mass. That when we introduce something into our bodies that’s really not meant, like if we have normal levels of testosterone and we’re introducing something to increase it, it’s going to malfunction our system.

And so a lot of times, in the short term, you might have symptoms such as impotence, hair loss, cystic acne, you can have gynecomastia, which is breast enlargement tissue, which you’ll often hear about in the body building culture, although they refer to it by an offensive name.

Now that’s the short term effects. The problem, though, and I say this problem, is a lot of men don’t experience the short term effects. So for them, they’re just getting the reward of this increasing muscle. However, many of them will experience long-term effects.

And the long-term effects are that it messes with your heart, that a lot of times it’s not uncommon when you hear of body builders who die at 40 of a massive heart attack, or certain athletes, that it can rupture and basically accelerate arthrosclerosis, and the hardening of the arteries in your heart.

It’s been implicated in everything from testicular cancer, there’s questions as to whether it can have neurological impact in terms of tumors, and things like that, in the brain.

On a psychological level, and this is something that actually Harrison Pope has done a tremendous amount of research, is this concept of what’s called roid rage, which is that, and Dr. Pope is one of the few people that have done these control studies, which basically, so what roid rage is, people who will take steroids, and then they get incredibly aggressive, and sometimes to the point of committing very heinous acts, and violent acts.

Now the argument within the community of people who use steroids, is like, well no, these are individuals who are aggressive anyway, and it’s not the steroids that’s making them aggressive.

Well Dr. Pope has done controlled studies using a fraction of, obviously what one can do ethically, a fraction of dosing of what people actually use, people who are screened to not have any history of mental illness, or violence, or anything.

And he found statistically significant differences in people who engage in anabolic steroid use, who would report, and who would have a loved one, because part of his research would, in some of these studies, would include a roommate, or a mom, or someone the person was living with, to rate their mood.

And some people had to withdraw from the study early because they were experiencing hypomanic, psychotic symptoms, very aggressive symptoms. I had a patient years ago who really, very nice kid, but suffered from BDD.

Not someone who would ever commit any kind of violence, and he knew, he’d started taking steroids, and he, luckily, got scared enough when someone had cut him, an old woman had cut him in line at, I don’t know, Papa Gino’s or something, and she didn’t realize she was cutting in, and he said, he’d like grit his teeth, and he swore at her.

And this is not someone who would do that. And then he felt this aggression. So that happens. So there are all these consequences.

Now, what’s problematic, Jenn, is that years ago, steroids was one of those things that was sort of the little secret, that no body builder or celebrity, certainly, wants people to think that oh, I got this body through steroids.

I actually met Hulk Hogan, when I was, I grew up in Somerville, and Hulk Hogan came to the World Gym in Somerville, I think it was 1984, 1985, and he is a massive person, I mean he is a huge person. And I thought, he’s got to be doing something.

No one can naturally look, and he had denied it for years, until he later in life admitted that in fact he did do anabolic, and he says, to his quote, that most of the wrestlers at that time were all doing steroids.

And he has a lot of health effects today that he lives with as a result of that, as well as all the physical demands of wrestling. But the problem is that it was this sort of best little kept secret, and now it has kind of spilled into the mainstream, in the ways that lots of substances have.

When we look at cannabis, and we look at other substances, so now you have people in the community that are like, hey it’s our right to do this, and if you can do it correctly, where you don’t have these effects, I don’t advocate the use of anabolic steroids.

If someone is prescribed it medically, testosterone, that’s one thing. But in terms of, I don’t buy into this notion that there is a correct way to do it, because at the end of the day, we don’t know what we’re doing to our bodies.

So there are people that, and then I’ve had patients that say look, if I die at 50, but I die having a perfect body, well that’ll be worth it. Like having body dysmorphic disorder, these disorders create sometimes a mindset where people feel that that’s kind of worth it for them.

I had a patient years ago say if they have to custom make a coffin to accommodate my large physique, then that will make me feel good. And that’s when you realize, whoa, this is a gripping kind of disorder in terms of what it can do to people’s way of thinking.

Jenn: Yeah. It can be life-threatening in some instances.

Roberto: Absolutely. Absolutely.

Jenn: Is there anything that you can share with us about the use of selective androgen receptor modulators, like SARMs.

I know if you were to look up SARMs online, it seems like the general message is that they have a similar impact on muscle mass to steroids, but that they’re somehow safer? I don’t understand it, but what do you know about it?

Roberto: I really don’t know much about that. I mean, with a lot of, so you have steroids, and then I think because of a lot of the negative, I mean, to me it’s accurate, information about steroids that then do have this sort of negative thing, you have these other products that are now out there.

Everything from harmless supplements that don’t help or harm, to some supplements that could be harmful, to these kinds of substances that I, that I really don’t know enough about.

But I know that in general what I always tell people is that anytime you’re dealing with something that you’re introducing into the body that the body doesn’t necessarily need in that way, we always have to be wary of it.

We don’t have longitudinal research in looking at this, and the truth is, people who often will engage in the use of these products are often people who feel a certain level of desperation of trying to gain.

That’s why you see it with the diet pill industry and all of that, that people sometimes don’t read the fine, they don’t read the fine print, because they’re just looking to get the results.

So I’m always wary of any of those things in terms of what they do, but I don’t know the research well enough, I guess, about that substance.

Jenn: I had another research question pop up. Are you familiar with any research on the prevalence of body image issues in homosexual men versus heterosexual men, and is there a difference between those populations?

Roberto: That’s a great question. So actually, in that first study I did on eating disorders, one of my, I had many hypotheses on various indices, and one of them was looking at sexual orientation, and hypothesizing that we would see a higher prevalence of gay men.

And if you look at all of the studies prior to that, which again drew men with eating disorders from clinical samples, almost all, I would say all of them, mentioned homosexuality as a risk factor, that being gay was a risk factor.

Now this is where the difference of clinical samples and community samples is important, and why as researchers we always have to make sure we’re tapping into every pocket. In the community-based studies, I did not find a higher prevalence of gay men with eating disorders. In fact, the majority of men in those studies were identified as heterosexual.

Now, that’s not to say that, I mean, obviously we know that these issues, and I’ve treated many men who identify as gay, who struggle with these eating issues. So I think our takeaway in a sense is that it’s not that it’s necessarily more pronounced in the gay community, but it may be more announced in the gay community.

And so what I remember in those earlier studies that I did, and even men, adult men, that I see at treatment, gay men tend to be more open about these struggles, with friends, with family, with people in the community.

And in that first study I did, actually, so many years ago, the men that were in treatment for their eating disorder tended to be gay men, and one of the, how I understand that, is a number of things.

So one is that gay men, because of cultural homophobia, have already, by the process of coming out, have already had to confront all these societal notions of what it means to be a man, or feeling, and being told culturally that they’re less of a man because they’re gay, and they’ve had to work through that.

They’ve had to courageously navigate that in their coming out process, and I think there’s a certain resilience that comes along with men, and for anyone who comes out.

But here where we’re talking about men, there’s a certain resilience that comes along with that, that when they then also have a body image issue, eating disorders, I find that it’s a little less stigmatizing for them, in the sense that they almost can find support, in a way.

Now how it might manifest differently, is that studies will show that men, and again, this doesn’t apply to everybody as an individual, but the group difference is that men tend to be more visually aroused by stimuli than women are.

So when you have men that are trying to attract other men, the dynamic of aesthetics might take on a different meaning than it does between a man and a woman. But even as we know, and this is where, again, we need more research, the gay community is not a monolith.

There’s so many different aspects, so earlier studies, when they would talk about the gay community, really was looking at often young, gay men that were maybe in club culture, and more youthful culture, who would have these experiences of, like I remember someone in an early research study saying he grew up in New York where there was a gay club that said no pecs, like no pectoral muscles, you don’t have the pecs, no sex.

And you don’t get admission into this club, because just you don’t cut it in this way. That there’s this certain attention, now within the gay community, what we know from body image is that in the 70s, it was this more slender look that was idealized, at least, again, culturally.

Now again, this isn’t with every gay man. And then when the AIDS virus hit, in the 80s, and particularly the mid-80s, the idea of being skinny started to actually be something that might be looked at as aversive.

And so I would hear from men in my studies of patients, gay men, who would say that, who grew up during that time, that said that they started lifting weights, and where anabolic steroids actually became more prevalent in the gay community to move away from the wasting syndrome of AIDS and looking healthy.

In addition, when you take something like muscle dysmorphia, because of homophobic violence, that a lot of gay men that I worked with started their compulsive weight-lifting as a result of survival, as a result of I need to be strong because I’m going to be bullied, I’m going to be harassed, and it sort of spiraled in that way.

So that’s something, the issue of safety and survival, and the body also being this kind of vessel of self-esteem, that we know what people who struggle with body image and eating disorders, it’s sometimes you’re dealing with underlying issues of trauma or self-esteem that it’s like, if I can make my body okay and perfect, then I’m okay and perfect.

And we know that gay men have had to deal with all of these sort of societal notions of homophobia that then, and then trauma as well, that might bring a different dimension to how they relate to their bodies than men who don’t identify as gay.

But as far as prevalence, I would say I see a lot of heterosexual men and boys who struggle with these issues. So I don’t think the statistics are much higher. I think they’re being identified differently.

Jenn: One of the things you already alluded to is about media imagery, and I know you had mentioned in gay populations, it was the wasting syndrome that folks wanted to steer clear of, because that was what people saw as being undesirable, because that was what the media was putting out.

I know that in the 70s and 80s, there was like David Bowie, androgyny, rail-thin chic. There was, in the 90s, as a product of the 90s, there was Kate Moss in a white, silk dress, like rail-thin bodies as being what was almost ideal for women, or women to be attracted to.

But it’s hard to find information about what’s being encouraged for men to think and consider about their bodies, and what the media is pushing on them. Do you have any insight into what’s being promoted about male bodies to men?

Roberto: Oh absolutely. So this is something that’s a real interest of mine because I’m, as you know, Jenn, I’m a lover of popular culture. I’m a music fan, a movies fan, I love, and I’m a consumer of all of that.

Jenn: You’d be a great trivia team member. Just saying.

Roberto: I have to say, I am pretty good at trivia. If it’s music trivia, I will dominate.

Jenn: I had a feeling.

Roberto: But absolutely. This is something that is of real high interest, and that I’ve done a number of studies on.

So what we know from a media perspective is really prior to the 1980s, the male body wasn’t so much a commodity. It wasn’t this currency of selling things, and whatnot. If you look at, whereas for women, historically, it’s been, but if you look at like the Marlborough man, none of his body was showing.

He was a rugged, some might even say slightly out of shape meat and potatoes diet, cowboy. But what did he exude was a sense of masculinity, and our societal notions of masculinity, and being rugged, and being tough. And that image was what’s pushed out there of what a man should be.

Now, what started to happen though in the late 70s early 80s is partly, I think, that advertisers realized oh wait a minute, if we can make half the population hate their bodies and profit off that, let’s make the other half of the population profit, and make money from it.

And so you started to see, and Dr. Pope and I did a study, actually, where we looked at advertising and we focused on women’s magazines from the 70s, 80s, 90s, and the proliferation of unclothed men was like this steep, I mean like, it was so high, whereas for women it was fairly consistent throughout the decade.

But we started to see it go high in the 1980s, where it was like more shirtless, and now it wasn’t just looking rugged, it was, you had to have the muscles, you had to have, so you started to see that, and it was working.

And one ad in particular that I often highlight that really is like the lightning bolt, is Mark Wahlberg in the Calvin Klein underwear ads. Now Mark Wahlberg, at the time, for those of you who grew up when I did, was Marky Mark, and Marky Mark was a rapper, he was Marky Mark and the Funky Bunch. Yes.

He was supposed to be one of the New Kids on the Block members, but didn’t work out, so he started his own thing.

So Marky Mark at that time, and I’m referring to him as Marky Mark, because of his persona at the time, was a sort of, he’s this tough rapper, and frankly, he was a bit homophobic, and he is, Mark Wahlberg, has since apologized for that.

Calvin Klein did the most brilliant thing from their advertisement perspective, is they realized, because a lot of that imagery of the male body had this almost homoerotic notion to it, so it was appealing more to and drawing upon gay men, more than it was men who didn’t identify as gay.

So they put Marky Mark in a Calvin Klein underwear ad at Times Square. And prior to that, Jenn, I mean straight men would never have spent $10 on a pair of underwear. It was like Fruit of the Loom, Hanes, that’s about it. No one’s going to buy designer fashion underwear.

Well, right after that, it was a zeitgeist. I mean, it just shifted everything, to the perspective that women who were in relationships with these men were buying this underwear, men who were in relationships with these men were buying these underwear, and men were buying this underwear.

And of course, Marky Mark had a very good bod, I mean he had a six pack, he was a very fit guy, and he still is a very fit guy.

So that exploded things, and then you started to see more of that imagery and everything from Abercrombie and Fitch, and Calvin Klein, but what’s even more interesting, and some might say frightening is one of the most fun papers that Dr. Pope and I wrote is what we call the GI Joe Study, and this was a study that supposed to be like an analogy to the Barbie study.

So in 1980, these researchers did a study where if they extrapolated the Barbie doll to human-like dimensions, they found that her dimensions would be completely unrealistic. Not even attainable.

And women’s rights groups, eating disorder advocacy groups, would pressure Mattel to change the dimensions of Barbie to say this is not a realistic standard. So after years of a lot of advocacy around it, Mattel did slightly change the dimensions, where now Barbie would be attainable if she were anorexic with breast implants.

So that’s as attainable as it got. So we thought what would that look like for boys? So I grew up in the 70s and 80s where we had action figures, and I bought action figures from this toy store and we did the same thing.

And GI Joe in particular has a history, you have of decades, and we found that boys action figures have been getting more and more muscular over the decades with a lot more muscular definition. But now one might argue, well these GI Joe are not the same guy, that they’re different.

But this is where, I mean it was very interesting and shocking, is that year, this was in the mid-90s, Star Wars had been digitally remastered and re-released in the movie theaters, and they re-released the action figure line, and Luke Skywalker, Han Solo, which is based on the same character.

Their action figures spent a significant time at the gym I guess between the 1970s and the 1990s, so much that it was, like Mark Hamill, the actor who plays Luke Skywalker, was quoted as saying oh my gosh, they put me on steroids, because the action figure was like, Luke Skywalker had him like, his pecs were showing, he didn’t even look like the character.

And also, I should say, that Princess Leia’s breast size tripled, like her action figure. It’s like, what? What is going on? That to me is what’s insidious, is one way, there’s this sort of, I’m poking fun at this, but let’s really think about this.

If there was a very conscious decision from these toy companies to say we’re going to alter this action figure that’s based on the same visual character, I mean the same character, to sell more of it, to promote, like why is Mark Hamill’s body was fine.

It’s like why, the action figure I had in the 70s I was playing, I thought he was so cool. Why is it that we need it to be, so we see it in action figures. We see it in video games. There’s a very, there was a popular video game at the time in the early 2000s called Duke Nukem, and I recommend for people to look him up.

Duke Nukem is this Rambo-like militaristic misogynistic character, very built, but in the Duke Nukem game, which this is a game that is, their biggest demographic are boys between the ages of 12 to 22, in one of the versions of Duke Nukem, if he finds the hidden bottle of steroids that he clicks on, his body gets maximized, and he can really obliterate his opponents.

Now let’s imagine that, what are we advocating here? If I told you, Jenn, there’s a video game here, if you snort a line of cocaine, and it makes your character have a lot more energy, we’d be in an outrage over it.

Or if there was a video game that had a girl take a bottle of diet pills, that’s egregious. That’s so, but here are these imagery, and these messages out there. If you look at the superman of today, very different than Christopher Reeves’ body, and there’s nothing wrong with Christopher Reeves’ body.

There’s nothing wrong with the, there’s definitely this sort of push, but what’s different, I should say, in a way more insidious when we’re talking about boys, is there isn’t a way that boys even understand that this is, that they’re consuming this.

I think for girls, unfortunately, there’s this normative discontent that you see with a lot of girls about their bodies, and there are these conversations that they can have as a result of that with people that say yeah, they’re aware of Photoshop filters, and all of these things.

Boys are being impacted by that, too. I mean, these apps that have, take the acne off their face, and put a little more hair on their heads, or whatever it is, but I remember years ago doing a talk to a health class in one of the local public schools.

Seventh grade boys, and a colleague of mine, she spoke to the girls, I spoke with the boys, and I said what are some of those media imageries, and people were listing them off the bat. And I said, how many of you feel kind of insecure sometimes? Or you feel like you’re hit by that, or it affects the way you feel about yourself?

All of the boys were like oh, not me. No way. I’m not going to be like, almost like it was a weakness to even acknowledge that you could be impacted by that.

And I said well, when I was growing up, I mean we didn’t have it to that degree, but I absolutely was impacted by, you see people whose body just took on muscle in a much easier way than mine did at the time, or how would you not be impacted?

And I remember, I’ll never forget this, young kid, he was 12 years old, he said you’d have to be kind of weak to be taken in by that. I’m my own person.

Now, I didn’t point this out to him because I didn’t want to embarrass him, but he’s saying this while he’s wearing pants that didn’t have a belt, that were sort of drooped down so that you can see the Abercrombie and Fitch.

The fact that his underwear was from Abercrombie and Fitch, he was wearing a shirt that was like, where the sleeves were cut off here at the sides, to kind of enhance, and his T-shirt was of Dwayne Johnson, of The Rock.

And I thought, that’s really interesting, that you’re showing me that you have no one, like when I was growing up, no one would be like hey, check out my Hanes underwear, you know, like no one’s going to do that. That was seen as actually like, wear a belt, don’t.

But the marketing of this, whereas my colleague said that all of the girls were like, of course we’re impacted by this. How are you not?

So boys don’t have, it’s almost like already this assault on their sense of masculinity to even say that they’re taken in by this in that way.

So now if you have a group of individuals who are taken in by it, who aren’t aware of it, who think it’s a weakness, but it’s still impacting them, how then do we reach those individuals for them when they do develop a real problem with it to know, hey, there’s treatment, and you can get help for this.

Jenn: I think that’s really interesting too, that there is almost an externalizing in female populations, and when you think about it, dieting groups, when you think the point counters, and the group weigh-ins, and expressing all of that, has been really heavily marketed toward women.

And then that leads to generations of women who have already bought into diet culture simply because they saw somebody that raised them going through it, so it has that trickle-down effect, and I’ve just never thought of it as being something that like, yes, it also impacts boys.

Roberto: Definitely. And a lot of times, when I’m working with a boy who struggles with body image, or eating issues, and a lot of times, the parents will feel guilty, and they’ll feel bad.

They’re like, I never thought, or rather I was, you’d read the books that’d say don’t talk about dieting in front of your daughter, be aware of how you talk about your body in front of your daughter. I never read anything that says around your children, like around your son as well.

Because even if it’s the mom who has negative body image, that can affect the boy, if you’re seeing that, or if it’s a father that struggles with negative body image, that could affect it’s daughter, and her view of body image.

So we do need to open that up to be more inclusive about the way that we’re looking at this, that it may not be diet culture, per se, but definitely this culture of building the body, and because studies actually show that boys who are underweight are bullied almost as much as boys who are overweight.

That being, whereas with girls, being seen as too skinny is not going to render a lot of negative reaction, per se, but for boys, if you’re too skinny, then you’re weak. You have no muscle.

But if you’re seen as obese, then you’re someone who lacks self-control, and you’re not strong, so it’s like, you need to be big enough to have muscle, but you know, but not be too skinny, you have to have.

So that’s what we find, and my dissertation actually, was a study that looked at this, where we had developed this computer program where men could click an image and make the image more or less fat, and then more or less muscular.

So on two axes, because a lot of previous studies in body image would conclude, through what they call figure rating scales, where they would ask, they would have like an anorexic, very thin image to an obese image, and they would ask women where do you see yourself, what’s your ideal.

For women who identified as heterosexual, what do you think men prefer in a female body. And studies will often show that women preferred an ideal that was unhealthily thin. They saw themselves as bigger than they truly were, and they thought men desired a thinner image than men in fact desired.

So when studies like that were done with boys, and with men, they said a lot of them would conclude that men generally are satisfied with the way they look, because some men preferred a thinner build, some preferred a larger build, so it all evened out.

Now of course, what those studies were lacking was the dimension of muscularity, that it’s almost like, it’s not a valid study if you’re just going on body fat percentage.

So when we did this study with muscularity, these were college students, that we found pretty significant results, that men, and then we actually did measure the body fat of all of these men, and their height, weight, so we had the correlation of what their actual body fat was with their ideal body fat.

And what they thought women preferred in them, and we found that on the body fat dimension, it wasn’t a big statistical difference that men idealized a body that was eight pounds less body fat. Not very statistically significant.

However, when we looked at muscularity, they idealized a body that was 25 pounds more muscle than what they currently had. Now we have differences.

And then, when we correlated data of eating disorder inventory, which is a popular questionnaire, of the various scales looking at feelings of ineffectiveness, of depression, of prevalence of bulimia, and bulimic symptoms, that we found that it wasn’t the men who were dissatisfied with their body fat that correlated with any of those scales it was the men that were dissatisfied with their muscularity that correlated with all of those scales.

So the more dissatisfied these men were, or rather the larger the gap between where they saw themselves and their ideal on muscularity, not body fat, the more, the higher they scored, on feelings of ineffectiveness, on a drive for thinness, which really was tapping into a drive for leanness, not so much thinness, for maturity fears, for self-esteem problems.

And so now, we see the data come through, and this is part of what we need more of in research and to attune to is that when we ask somebody, are you, even a lot of the questionnaires, understandably, are going to be based upon how females define their body image.

I’m dissatisfied with my thighs. Do I check always, rarely, never? Men don’t, I remember in this survey, because that’s what we used, that a man, this was a very bright college student, he said what are thighs? He goes, I don’t know what a thigh is. And I said, basically like your quads? And he’s like oh, okay. He goes you should just put quads, you know?

But it’s true, but even for a man to say I’m dissatisfied with my thighs, there’s emotion that these men have in that, versus if you say are you dissatisfied with your quads? A lot of men would be like, yeah. They could, are you dissatisfied with your biceps, or things like that, but languages sometimes has to be a little different.

Jenn: I know we’ve talked a lot about image issues and boys, and what happens with that as they age, but do you think that body image challenges still exist for men who are 40 and older?

Roberto: Yes, and I’m glad that you asked that, because a lot of, and this is true for men and women, in the body image eating disorder space, is it’s so much more broad than how we think.

I mean, even when we, the image of eating disorders for a lot of people still is the higher socioeconomic Caucasian woman, when it exists, as we’re talking about, with men, it exists in Hispanic, African-American, Asian cultures, it exists in lower socioeconomic cultures.

It exists in LGBTQ populations, I mean that it’s much more broad. But one of those, probably the one that’s the most that I failed to mention in that is young. So the young affluent Caucasian female, I treat a lot of men, actually, over 30, over 40, who struggle with body image issues.

And it can be things like, they’re either perceptions, or actualities of whether it’s weight, whether it’s hair loss, whether it’s preoccupation with genital size, whether it’s the functionality again of their bodies. I’ve worked with men who obsessively lift weights and exercise at 50, because they don’t want to be seen as weak.

And the other thing, too, that can get overlooked, is cosmetic surgery, which is, just to give you a statistic, in 1990, I think it was 1992, the American Society for Plastic and Reconstructive Surgery had released statistics that showed that about 6,000 men had liposuction, where you removed unwanted body fat. 1992.

Five years later, in 1997, 25,000 men in the US had liposuction. So in a five year period, it quadrupled. Now, what happened in that five year period? So aside from all of the other things we’ve been talking about, the American Society for Plastic and Reconstructive Surgery, their advertising went to plastic surgery, cosmetic surgery, not for women only.

And you’d have these good-looking guys that would talk about, like, I had a nose job because that was getting in the way of me getting dates, and this, and so now you have men who are getting cosmetic surgery all the time.

I’ve worked with men who have some of these issues of body dysmorphic disorder who’ve had pectoral implants, who’ve had calf implants, who’ve done penile enlargement to do things that are, sometimes really risky things, like very dangerous things. But older men also have sometimes more financial resources to do those things.

So a lot of times, with that area, I’ll work with older men who might have these sorts of financial resources to sometimes do these sort of procedures, and a lot of them aren’t so happy about it afterwards, because they’re thinking it’s going to solve this inner issue, that sometimes give rise to these.

But it absolutely exists with older people, and this is true for women as well, that older women, older men, who struggle with these issue sometimes don’t feel that there’s a space for them.

They say, and I’ve had men tell me this, that they go to support groups, and it’s like, 19, 20, 21 year olds, and they’re 55, and that person is old enough to be their son, and that doesn’t mean that there still can’t be a commonality, but we need, we need our community of those things make a difference sometimes.

And just like for someone whose LGBTQ, they could be in a space with people who don’t identify that way, but they also need a space of other people who identify that way, being someone who is African-American, or Hispanic.

There are different issues around body image and things like that, and the way the body is seen, and perhaps that we see in Caucasian, with individuals who are white. So there’s a lot more work that needs to be done to expand that.

Jenn: Understanding that there are plenty of body positivity and body acceptance campaigns that exist for women, how do we encourage more body acceptance in male populations?

Roberto: Yeah, that’s a big question. I think, on one hand, you have this term the dad bod, is one of these terms that half the time it’s used, I think in that body positivity way, and half the time it’s used in this mocking kind of way.

So I think, even I had a patient once say to me, I’m not sure if that’s a good thing or a bad thing, when people say that, like hey great job, you know, like dads will be, there’s a confusing mixed message around that.

I think in general, with men and women, is this shift, and this is what’s unfortunately with social media, which has been shown to be a lightning rod for body image issues, and even when Dr. Pope and I wrote “The Adonis Complex,” that was in 2000.

There was no social media then. If we ever did an updated version of that book, we’d have to have a whole area just on this research of social media, and how that affects the way that people are seeing their bodies.

At the end of the day, even with the body positivity movement, there are some studies that have looked at, and saying that, even though the intention is not to instill more body dissatisfaction, that sometimes that’s what happened, because even if people let’s say are posting their bodies, regardless of whether they’re in a larger body, a smaller body, it’s still this objectification in some ways of their body.

And so unfortunately younger people are still taking from that as oh my body is still something that I have to display. It’s still something that’s going to get likes, whether it’s fitting the societal image of what it should be, or I’m proud of the fact that it’s not fitting the societal image of it, but I’m still looking for that validation of people telling me that that’s okay.

And so I’m torn with how I think we need to do, it needs to be more work, and more nuanced as to how we navigate that, because I want people, I think the intention is great for people to just be happy with where they’re at.

And that doesn’t mean that people can’t want to lose weight, or people don’t want to get more fit, or whatnot, as long as it’s in a healthy way, that’s not impairing their lifestyle, it’s not going against other values that they have, that we need a more regulated space of how we relate in that way to our bodies.

So I think there’s just a long ways to go, because I was reading an interview with actor Jonah Hill recently, where he said I don’t want anyone asking me or commenting on my body at all. Even when people say you look great, I don’t want to hear that, because that means you’re still viewing me through this lens of my body. I’m an actor.

And I feel for him. Adele, one of the most gorgeous voices, that poor women is probably going to hear questions about her weight loss, even if the intention is complimentary, she’s a singer. She’s not a spokesperson for weight loss. She’s there as a singer.

Why are we paying so much attention to that in that way? So I think we have a long way to go in my mind as to what we really mean by body positivity.

Jenn: I think we have time for one more question, and it’s a fairly important one. Somebody wrote in about saying that they offer outreach programs that address male body image and eating concerns, but the challenge that they’re running into is getting males to attend.

So what suggestions do you have to help address these issues with college men and what kind of outreach or programming have you found to be really successful in your own experiences?

Roberto: Yes, that can absolutely be a challenge, because it’s so many different levels of having the available space, and then having men feel welcome to come in and have them feel not as much shame to engage with that.

So one of, as an example, Harvard University has an organization called ECHO, it stands for Eating Concerns Hotline Outreach. And they’re Harvard undergrads who run a peer hotline for people who have, for students, who have eating concerns which I think honestly every college should have.

I have had the pleasure of consulting with them for over 20 years now, to talk about men, how to outreach to men, how to make that space more available, and they have seen an increase in calls from men. I think part of it is also how we outreach, and how we talk about it.

Sometimes even I remember a graduate student who had reached out to me for advice on how to recruit men for body image studies, and the first thing that came to mind is don’t put the word body image in the ad, because even saying are you concerned about your body image, that vocabulary, at least today, is not really something that generally boys are acquainted with.

Or, like you said, that trickle down for women of diet culture, that makes so much sense to them, that sort of phrase. With men, that word is sometimes introduced to them in therapy, when I introduce that term of what that means.

Now I might put an ad that says are you dissatisfied with your fitness goals? Now I’m going to get a lot of calls from men who don’t have body dysmorphic disorder and whatnot, but that’s fine.

I’d rather get a lot more and screen the ones out, but then I’ve captured the ones who truly have that. But with groups like that is, do you feel like you’re spending too much energy on thinking about, whether it’s your physical appearance, or your fitness goals, or something like that, when you’d rather be putting it into something else, that might get more of a draw.

This idea of almost presenting to men that we, that they’re not optimizing themselves, the idea that there’s so much wasted energy for a lot of people of all ages, men and women, into I need to look a certain way, look a certain way, and what we want them to understand is what is that energy being taken away from?

And a lot of times, that language can be more appealing, rather than, unfortunately, what men find stigmatizing, this weakness, this pathology model, in that kind of way.

The other thing is sometimes I’ve found that if people run a group for just athletes, that I think men are more likely, for example, to go when they feel that there’s going to be much more commonality, more so than with women. I think with women, you could have body image concerns, and you’re going to have women of all different walks of life enter.

I’ve found patients that I’ve worked with who approach that if they find out it’s going to be athletes, because there’s a lot of male athletes who struggle with eating disorders, they’re more likely to attend than just men in general, because they’re like, well I don’t know if I’m going to really relate to that.

Or if you have men of color, or if you have gay men, that I find that, and now you might get two or three people, but you might get more of a response in support sometimes, the more nuanced it is.

But my feeling is that to still just keep doing it, because sometimes just the visibility of those groups, it starts to plant a seed for that young man, or that older man that says, you know what? That group’s been, I’ve seen that flier for the support group for a year now, maybe now I can make the call, because it’s just there, that the infrastructure is there more.

Jenn: I know we’ve already gone over an hour, so I want to be respectful of your time, and I always feel weird saying this about really heavy subjects with you, but this was fun. So, I always have a great time talking to you. So thank you, again, for another fun hour.

Roberto: You’re welcome.

Jenn: This was fantastic. And anybody tuning in, thank you so much for joining. This actually concludes our session about men and body image.

Until next time that you tune in, be nice to one another, but most importantly, be nice to yourself. And Roberto, thank you again for all your pop culture knowledge, too.

Roberto: Thank you.

Jenn: Take care.

Roberto: My pleasure. Bye-bye, everyone.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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