has received far
less scholarly
attention in
the past two
decades.
heterosexual counterparts. Definitions of ‘body image’ and approaches to its study are varied and the term ‘body image’ is often used to mean different things by different researchers (Cash, 2004). This can create confusion and variability across studies (Grogan, 1999). For many, the focus is entirely on perceptions of one’s own body attractiveness and perceptions of body size, specifically thinness (Pruzinsky & Cash, 2004).
Of particular concern to health practitioners in this context are issues around body satisfaction and body esteem, body image disorders, and associated spectrums of body dissatisfaction and risky behaviours.
Body image, as a concept, ‘refers to the mental picture one has of his or her body at any given moment in time’ (Kaiser, 1990, p.98) or ‘a person’s perceptions, thoughts, and feelings about his or her body [including]
body size estimation (perceptions), evaluation of body attractiveness (thoughts), and emotions associated with body shape and size (feelings)’ (Grogan, 1999, p.1). As part of the RaRE Study, there was a conscious effort to adopt and develop a definition of body image that encompassed contemporary usage that includes ‘our experiences of our physical appearance [recognising] that embodiment entails more than self-perceived aesthetics’ (Cash & Pruzinsky, 2004, p.510).
From a data-led definition that can be used across a range of health and social-care environments, the RaRE Study uses a theoretical position of embodiment that – as well as aesthetic considerations – includes levels of competence (e.g. physical fitness, athletic ability, kinesthetics) and experiences of the functioning body (e.g. sensation, perception, the ageing processes) which many conceptualisations of body image often fail to capture (Cash & Pruzinsky, 2004). To encourage engagement across a range of audiences at the various stages of design, data collection, analysis and dissemination, as well as to improve strategies of assessment (Thomson, 2004), the RaRE Study uses two specific foci: body satisfaction (and dissatisfaction;
Tylka, 2011; Pruzinsky & Cash, 1990) and cognitive-behavioural investment (Thomson, 2004) such as drive for changes to muscularity or thinness (Kelley, Neufeld & Musher-Eizenman, 2010; Tod, Morrison
& Edwards, 2012). Specific experiences of distress are discussed in relation to current theoretical models and the language of participants themselves, such as ‘body dysmorphia’, ‘body esteem’, and ‘eating disorders’ (Pruzinsky & Cash, 2004). This has allowed the data to be collected and analysed from ‘cognitive-behavioural and feminist perspectives’ whilst maintaining reflexivity about discursively constructing the medicalised body (Olivardia, 2004).
6.1. Body image disorders
Disturbances in body image have been defined as having three aspects:
perceptual, attitudinal and behavioural (Thompson et al., 1999). There are a number of psychological/psychiatric diagnostic- type constructs and terms used to describe and define body image concerns. These
include body image dissatisfaction; body image disorder; body dysmorphic disorder (BDD); and muscle dysmorphia (MD), a sub-type of BDD. Whilst distinct, these constructs share some characteristics and it is important for the purposes of our study to clarify these terms and distinctions.
Lambrou, Veale and Wilson (2011) described people with body dysmorphic disorder (BDD) as having an unrealistic ideal as to how they should look. BDD symptoms include a preoccupation with the belief that a specific body part is defective or deformed in some way.
The preoccupation is excessive enough to cause distress or significant functional impairment, such as in the social or employment sphere.
BDD is distinctive from the body shape dissatisfaction of anorexia nervosa or the body delusions of a psychotic disorder. BDD shares characteristics with obsessive compulsive disorder (OCD) but with some significant differences. According to a study by Phillips and Diaz (1997), BDD patients are more likely to have suicidal ideation and are at greater risk of developing major depression or social phobia than participants with OCD.
Muscle dysmorphia (MD) is defined as having a persistent belief that one’s muscles may be small and insufficient, despite having enough muscularity. Along with a heightened drive for muscularity, men with MD tend to feel ashamed of their bodies, and hence avoid their bodies being exposed to others. They frequently compare their bodies with other men’s and seek reassurance about their appearance (e.g. Chaney, 2008, Maida & Armstrong, 2005). These men also manifest symptoms of body dissatisfaction, body dysmorphic disorder and OCD, hostility, depression, anxiety, and perfectionism (Maida and Armstrong, 2005). A study that compared men with BDD who had either muscle dysmorphia (MD) or BDD without MD found greater psychopathology amongst those with muscle dysmorphia. This included higher rates of suicide attempt, higher rates of any substance use disorder, anabolic steroid abuse, and poorer quality of life (Pope, Pope, Menard & Fay, 2005).
Another relevant concept is that of body fat dissatisfaction. In many affluent societies there is a growing trend towards greater proportions of society experiencing being overweight or obese, both as adults and in childhood (Health and Social Care Information Centre, 2014;
National Institute of Diabetes and Digestive and Kidney Diseases, 2012). Alongside that trend, dissatisfaction with body fat and pressures to attain a leaner body are also high. Even very young children express body fat dissatisfaction and it has been reported in boys as young as six (McCabe & Riciardelli, 2004). A study of 256 ethnically diverse, British boys and girls aged 11-14 years found that the majority were dissatisfied with their bodies in terms of fatness (Duncan, 2006), indicating that the issue is not only common for girls, but also for boys. A study by Bergeron and Tylka (2007) concluded that body fat dissatisfaction may be of great importance to males’ psychological
well-being even after taking account of their ‘drive for muscularity’.
They also concluded that for men, body fat dissatisfaction is empirically distinct from the drive for muscularity.
To develop an ideal body type, people engage in body change behaviours such as dieting, binging and purging, exercise (which can be excessive to the point of injury) and the use of performance and body enhancing drugs including anabolic androgenic steroids (AAS), which are usually obtained illegally (Grieve, Truba & Bowsersox, 2009).
Prolonged use of AAS in particular can pose potentially serious mental and physical health risks (Thiblin & Petersson, 2005).
6.2. Prevalence of body image issues
A specific desire to be more muscular is common in Western men. In the United States, for example, the vast majority of undergraduate males (up to 90%) in one study expressed this desire (Frederick, Buchanan, Sadehgi-Azar, Peplau & Haselton, 2007). At about the same time, Rief et al. (2006) reported a prevalence rate of BDD (as defined by DSM-IV) in the general population of 1.7%. However, they concluded that these reported rates are likely to underestimate the true prevalence as the study excluded those with weight concerns, some of whom may have had BDD.
Some studies have found that gay men have greater body dissatisfaction than heterosexual men (Peplau et al., 2009; Tiggemann, Martins &
Kirkbride, 2007). Wrench and Knapp (2008) found that compared to their lesbian and bisexual counterparts they found significantly higher levels of body image fixation in gay and bisexual males as well as more negative attitudes towards and dislike of fat people, ‘weight locus of control’, discrimination against others’ weight/ physique, and depression.
Additionally some evidence suggests that there may be a higher incidence of BDD amongst gay men compared to heterosexual men; however, an obvious tension is the omission of bisexual men, or the conflation of bisexual identity with either a gay or straight identity (Barker et al., 2012). For example, the following studies do not include bisexual men.
Kaminski, Chapman, Haynes and Own (2005) found that compared to their heterosexual counterparts, gay men reported dieting more, being more fearful of becoming obese, and were more dissatisfied with their bodies generally as well as with their muscularity. They were also more likely to hold distorted beliefs about the importance of having an ideal physique.
This has also been supported by others who also found that gay men were more pre-occupied with being overweight, had lower appearance evaluations and more negative feelings about their bodies (Lakkis,
Ricciardelli & Williams, 1999; Peplau et al., 2009; Tiggemann et al., 2007).
Tiggemann et al. (2007) studied gay and bisexual men separately, and found that although they both had a thinner and more muscular ideal, gay men still had significantly thinner preferences than bisexuals and