THE BLOG

Body Dysmorphic Disorder: Myths, Masculinity, and a War to be Won

25/09/2015 18:13 BST | Updated 25/09/2016 10:12 BST

We young'uns are always banging on about mental health, aren't we? Challenging stigma, raising awareness, and sometimes even sharing our stories - often at some cost to our personal wellbeing.

Will we ever give it a rest?

(Spoiler alert: nope).

Earlier this week, I was asked to contribute to a BBC Radio Five Live programme on body image and, in particular, body dysmorphic disorder (BDD). The parameters of the conversation were broad and seemed to be couched in terms of society's generalised concern with looks and appearance. I was delighted to offer some of my musings and I hope I was even vaguely helpful, but time constraints prevented me from exploring things in more detail and there was so much more I wanted to say.

I'm often asked about what I think causes BDD and in reality there are many causal factors: personal (traumatic events and life stressors), genetic (predisposition to obsessive-compulsion and/or history of anxiety disorders in close family), and socio-cultural (every god-awful 'are you beach body ready?' ad you've ever seen). There is also plenty to be said about BDD in relation to gender normativity and sexual orientation - so brace yourselves, because some of my thoughts on this are about to spill out of my brain in a disorderly fashion.

Before they do, perhaps it would be useful to dispel a few myths. There are many things that BDD isn't: It isn't indicative of a defective character; it isn't a condition reserved for the selfie generation; it isn't a pathologization of vanity or narcissism; and it isn't a made-up condition used by psychiatrists and pharmaceutical companies trying to cash-in on a contemporary preoccupation with bodily perfection (apologies to any Daily Mail readers/basement-dwelling fans of conspiracies).

It is, however, like most mental health conditions, deeply misunderstood, readily misrepresented, and much more nuanced than popular opinion might have you believe.

BDD is a term used to describe a set of symptoms and behaviours. These may include an unhealthy and dominant obsession over a physical 'flaw', real or imagined; pulling at one's skin; ritual 'checking' behaviours; social withdrawal and low mood caused by intense dissatisfaction with body shape and/or image, and so the list goes on. Left untreated, these symptoms can lead to a significant disturbance in a person's capacity to socialise, work, study and live. It can lead to other, frequently co-morbid psychological conditions, such as an eating disorder (as was the case for me), clinical depression, and/or anxiety disorders such as agoraphobia. The condition can even be fatal, with regular bouts of suicide ideation not uncommon.

Crucially, the one thing sufferers share is an obsessive over-evaluation of body image and shape in relation to self-worth and value.

My relationship with BDD began in my early teens and I believe it is linked in no small part to my sexual orientation. I grew up in Northern Ireland - home of the beautiful Mourne Mountains and politicians with colourful criminal records. Sadly, these six counties are not a safe place for anyone who doesn't identify as heterosexual. Even many of our aforementioned politicians are outspoken in their utter contempt for anything that isn't a white, middle-aged, moustachioed, heterosexual man. A quick google of 'DUP and homosexuality' should confirm this (although I warn you that researching this particular subject may induce vomiting).

The fact is, in Northern Ireland, my identity is circumscribed by what it is not: heterosexual.

So as I dragged myself kicking and screaming through adolescence, I just felt 'wrong' somehow; deviant and 'othered' as I struggled with my attraction to other boys my age. As a vulnerable teenager, I internalised all of the homophobia I witnessed around me, and I don't think it's surprising that this deep distress also developed into an obsession with how I looked or, rather, how I presented myself to the world in the most literal sense.

As I busily policed my thoughts and behaviours, I also began to police my physical form. I became convinced that I was grossly overweight and just 'ugly' in some non-specific, terrifying way. I found myself both compelled to look in and horrified by reflective surfaces; each time I saw myself in a shop window, my body looked totally different to how it looked in the last one. I couldn't go anywhere without sweating profusely and feeling like everyone was staring at my grotesque, deviant body. I could practically feel their disgust, their vitriol, their venom, burning into my skin. I walked around school, and then even around university in Edinburgh, feeling as though a spotlight was on me, an anvil about to drop at any moment.

There is no doubt that, for me, there was a direct correlation between living in an openly hostile, homophobic society, and developing BDD. Growing up in Northern Ireland taught me that the world was a dangerous place and I needed to have control over how I presented myself within it if I wanted to stay safe. A core belief such as this, coupled with certain character traits such as a tendency for extreme perfectionism and low self-esteem, therefore created a space in which a body image disorder, and latterly an eating disorder, could flourish.

And flourish it did.

In terms of gender, BDD doesn't discriminate one way or another. Yet, according to statistics from the National Institute of Clinical Excellence (NICE), women account for the overwhelming majority of body image and eating disorder diagnoses in the UK. I don't believe that these statistics reflect reality. So we must therefore ask why men are statistically more unlikely to present themselves to their GP with body image distress. The answer, of course, is excruciatingly complex (never mind the fact that BDD is notoriously undetectable due to the lack of insight experienced by sufferers and a lack of awareness amongst even trained professionals), but there is no doubt that societal expectations of masculinity play an enormous part in the reticence of men to speak up, seek help, or even recognise that they might have a problem with body image.

Quite simply, contemporary notions of what it means to 'be a man', emotional resilience and a total detachment from 'superficial' or 'feminine' concerns such as looks and appearance, for instance, are utterly and disastrously toxic. Men are trained to be instinctively hesitant to express any emotion or enact any behaviour understood to be antithetical to their masculinity, which in turn is perceived as the defining feature of both their worth and their identity. (Men even have to buy 'man-size' tissues - presumably for big manly tears, reserved only for when you dislocate your pelvis playing rugby or for when Marco Pierre White is chopping onions).

So what do unrealistic expectations of 'masculinity' mean for male mental health?

It means that men are much less likely to seek help for psychological symptoms which are causing distress. It means that men are statistically much, much more likely to commit suicide, and it means that we, as a society, are training a generation of young men to police their behaviours and actions, much as I had to do in my own adolescence, which leads them to police their physicality, too.

A little known but increasingly widespread form of BDD is muscle dysmorphia. How many men do you know who are, frankly, obsessed with 'gains' and looking as 'big' as possible - but are never quite satisfied? I think it's time to start asking questions. Could it be, perhaps, that society has consistently stifled male emotional expression and, consequently, men are deeply ashamed about their secret capacity for societally-determined 'feminine' emotions? Are they therefore compensating through making themselves appear as 'masculine' as possible? No matter how much theorising we might do about the ostensibly 'new' phenomenon of muscle dysmorphia, the point is this: prescriptive notions of gender, and in particular masculinity, are turning many men towards destructive behaviours. Like many forms of body image disorders (and their natural bedfellow - the eating disorder), these obsessive behaviours, cognitive distortions, and the correlation of self-worth with body image, are often symptoms of deeper psychological distress.

Anyone who has suffered with BDD, totally irrespective of gender or sexual orientation, faces a civil war between body and mind each and every day. It is a war that cannot be won alone, and what's more, it's a war that many people don't even realise they shouldn't have to be fighting. It's one that I fight each and every day and have done for the best part of the last decade, so if challenging ridiculous gender prescriptivism and cultivating an open, tolerant society in which we aren't fat-shaming, bigoted homophobes (I'm looking at you, Northern Ireland) might go at least some way to winning the war against BDD - then please, let's all try and do that.