Body image disorder in adolescent males: strategies for school counselors.

In recent decades, men have been bombarded with images in society that depict the "ideal" male: strong, muscular, lean, with perfect features. What many adolescents do not realize is that most of the male bodies that they idealize can be acquired only with the use of anabolic steroids. Thus, many adolescent boys find themselves pursuing a body type that is impossible to obtain. By the time these boys reach adulthood, mare, have developed an eating disorder, such as bulimia, or an image disorder, such as muscle dysmorphia. In this article, the authors describe body image disorders in adolescent males and offer intervention strategies for school counselors.

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   Seth, a 17-year-old wrestler, is worried about
   his upcoming weigh-in for a match. Although
   he has taken various over-the-counter products
   to help him gain muscle mass, and has
   lifted weights 6 days a week for the past 4
   months, he is now worried about weighing
   too much to qualify today. After spending the
   night sleeping in garbage bags to help him
   "sweat off" any excess weight he can, Seth,
   clad in two layers of sweatpants and three layers
   of sweatshirts, is running full-speed on a
   treadmill one hour before his weigh in. After
   the match, Seth will go out eating and drinking
   with his friends, and the next day the cycle
   will start again.

   Brian, a high school freshman, dreads going
   to gym class each day. At 6'2" and 130
   pounds, Brian feels that his muscle development
   is well below other boys his age.
   Spending each night feeling his arms and
   counting his ribs in front of the mirror, Brian
   refuses to go to the gym, too afraid that others
   will make fun of him, and instead overeats
   constantly in an attempt to gain weight. Today
   in physical education, the all-male class is playing
   "shirts and skins" basketball. Knowing
   that he will be on the "skins" team, Brian is
   trying to think of a way to get out of class.

A UNIVERSAL PROBLEM

For years, the public has been aware of eating disorders in women, especially the conditions of anorexia nervosa and bulimia. We have learned that one's body image is a complex configuration of the physiological, psychological, and sociological sell; and that a woman's eating disorder affects all of these areas until it eventually consumes her life (Parks & Read, 1997). Research results show that body concerns, usually the belief that one is too fat, are much more prevalent in women than in men (Cohn & Adler, 1992; Davis, Dionne, & Lazarus, 1996; Hoyt & Kogan, 2001). Thus, counselors have developed a sensitivity to women with body image disorders, but they largely have neglected men.

The recent public exposure of female body image and eating disorders has led women to confront society's demanding and often impossible ideas of beauty and perfection. As a result, women are being empowered to speak openly about such issues. However, men, who also receive their cues about societal expectations communicated through the media, often believe it is taboo to talk about their feelings. They are painfully aware of the cultural proscription regarding insecurity about their looks (Pope, Phillips, & Olivardia, 2000). Regardless of this silence, contemporary researchers on body image and ideals are reporting a growing trend toward male body obsession (Pope et al., 2000). The purpose of this article is to raise the issue of adolescent male body image concerns and, by way of case illustrations, to provide strategies for school counselors to address these issues.

THE IMPOSSIBLE DREAM

The current understanding of the etiology of body image disorders in boys and men is incomplete, restricted by limited research (Philpott & Sheppard, 1998). We do know that the preference in society is toward mesomorphic (muscular) males, and there is an aversion toward endomorphic (fat) and ectomorphic (thin) males (Weinke, 1998). Therefore, many boys and men who fall into the endomorphic or ectomorphic category recognize that they do not fit the ideal and thus strive to obtain the more mesomorphic body that they see in television and movies, in magazines, and on romance novel covers. Additionally, and perhaps more harmful, are the mesomorphic males who strive to become even more muscular, looking at a body type that, for most, is impossible to attain without the use of anabolic steroids (Pope et al., 2000). These men are doomed either to spending their lives chasing an impossible dream or to taking supplements and drugs that have very negative effects on overall health. Hoyt and Kogan (2001) discovered that, on average, men tend to emphasize physical attractiveness in relationships more than women do, which might imply that, even though a woman may accept her partner for how he looks, the man may continue to be dissatisfied with himself.

THE INFLUENCE OF THE MEDIA

In spite of the "impossible dream" and the harm that can come from pursuing a Mark Wahlberg- or Fabio-type physique, men continue to hold up those figures as the ideal for what makes a man. Grogan and Richards (2002) found that the adult ideals for the male body include "perfect pecs," "defined stomach muscles," and being "healthy and fit," "toned," and "athletic." It is no surprise that the ideal man has been reduced only to a physical image. For example, the Charles Atlas ads that ran in the 1940s revealed a 97-pound weakling who had sand kicked in his face on the beach by muscular "real men" until he finally built up his own body. The message was that to be a "man," one had to have a powerful presence in the world, a masculinity represented by muscles, conveying power and control (Weinke, 1998).

Current magazine advertising has become equally damaging in promoting this male image. Kolbe and Albanese (1996) conducted a study to evaluate portrayals of men when appearing alone in magazine ads. Examining samples from six different male-audience magazines, the researchers found that the majority of the men in the advertisements represented the male icon as strong and muscular. Several of the sampled magazines, such as Rolling Stone and Sports Illustrated, appeal to a large adolescent male population, which means boys are being bombarded with these images at the very age when they are deciding for themselves what kind of man they should be.

The rise of the male ideal as a sex symbol also has become prevalent in magazine photographs. For example, in 1958, Cosmopolitan magazine had only 6% of its male models undressed in some way (compared to 17% of female models), but in 1998 it had 32% of its male models undressed (compared to 27% of female models). Many of these photographs were used to sell products that had nothing to do at all with the human body (Pope et al., 2000). Pope et al. also found that the Playgirl centerfold has shed an average of 12 pounds of fat and gained an average of 27 pounds of muscle in the past 25 years. With the increasing emphasis in the media of a lean yet muscular male body as the ideal, it is no wonder that so many boys and men are becoming dissatisfied with their own bodies and are paying incredible costs to achieve the "perfect" body.

Finally, even toys have changed over the years to promote an ideal male physique. Pope, Olivardia, Gruber, and Borowiecki (1999) noted that the increase in muscularity of American action-figure toys over the past 30 years exhibits a greater level of muscularity than even the top bodybuilders! For example, one can consider the evolution of the G.I. Joe figure. In 1964, G.I. Joe was 5'10" tall, had a 32" waist, a 44" chest, and 12" biceps, which was a figure reasonably attainable by most fit men. By 1974, G.I. Joe had developed quite defined abdominal muscles, sporting the now-popular "six-pack" look, and by 1991, G.I. Joe had slimmed down to a 29" waist and increased to a 16 1/2" bicep (Pope et al., 2000). With young boys exposed to a G.I. Joe who looks like that, it is no wonder that they are becoming worried about their own bodies at younger ages. What these boys and men do not know is that most of these figures are not the result of healthy eating and working out, but rather the result of anabolic steroid use, dehydration, and other unhealthy habits.

ADOLESCENT MALES AND BODY IMAGE ISSUES

Regardless of the limited research on the topic of male body image disorders, Sondhaus, Kurtz, and Strube (2001) found a positive correlation between body attitudes and self-concept, and these attitudes were prevalent as early as adolescence, the pivotal period when boys are strengthening their self-concepts and searching for identity. In interviews with adolescent males, Grogan and Richards (2002) learned that boys viewed the ideal man as having "muscular legs" and a "good tan," who usually is a "bodybuilder" or a "boxer," and whose muscles are contained in the "arms," the "chest," and the "back, biceps, and triceps." Thus, boys learn early on that their identities are closely tied with the physical characteristics that they see in bodybuilders and athletes. These high standards cause many young men to become dissatisfied with their own appearance in pursuit of this ideal.

Muscle Dysmorphia

When people think of eating disorders, many tend to consider anorexia nervosa and bulimia to be the two main labels under which all people fall. The popular conception is that eating disorders result front people thinking that they are "too big" or "too fat." However, a third disorder, which is becoming more and more prevalent among adolescent and young adult males, is muscle dysmorphia. Muscle dysmorphia (colloquially known as "bigorexia nervosa" or "reverse anorexia") occurs when one has an excessive preoccupation with body size and muscularity, even if he already has a toned and muscular body (Pope et al., 2000). Consider the earlier case of Seth the wrestler, who probably spent hundreds of dollars on supplements and hundreds of hours at the gym to make himself bigger, when he very likely already had a healthy and desirable physique. Remember also the case of Brian, who became consumed with thoughts of inadequacy about his body but felt powerless to make healthy changes. Instead, he relied on overeating to gain what he saw as the ideal male physique, probably continuing to foster an unhealthy self-concept that will follow him into adulthood. What is even more distressing is that these boys will suffer in silence (Keel, Klump, Leon, & Fulkerson, 1998), adhering to what William Pollack (1998) called the "Boy Code of Silence," rather than seeking out help from the caring adults in their lives.

Peer Pressure

Peer pressure is also a problem for adolescent boys. As more boys become attuned to the male ideal presented to them in society, they also become more adept at identifying the shortcomings in themselves and, when that process becomes too painful, they begin to point out the physical shortcomings in others. On the flip side, boys who themselves do not fit into the concept of the ideal male image feel a silent peer pressure that they begin to enforce on themselves. In a series of interviews with 16-year-old boys, Grogan and Richards (2002) spoke with a boy named Tom, who said, "If you've got friends who are, like, quite big in build, you want to be the same as them. Although you might not be able to do anything about it, it's on your conscience all the time. You want to be that sort of size" (p. 229). Tom represents the voices of so many other teenage boys who see the men with bulging biceps and rippling abdominal muscles and ask themselves, "What's wrong with me?"

Health Problems

Many people--including parents, teachers, counselors, and coaches who observe boys obsessing over their bodies--perceive that these boys are just trying to be healthy. However, overall health barely fits into the picture for boys who are developing body image disorders. Their reasons for wanting to look good are mostly cosmetic rather than health related (Grogan & Richards, 2002). Adults need to make themselves aware that the eating and body disorders that boys face are very similar in etiology to those that girls face. Eliot and Baker (2001) questioned and reviewed the charts of 40 adolescent males in the Eating Disordered Clinic in Boston and discovered that the courses and outcomes of the disorders were quite similar to those of females. Keel et al. (1998) reported that, like their female counterparts, males have disordered eating and dietary habits that many times occur in the absence of significant weight problems, and that disordered eating in males, like in females, appears to be more psychological than physical. Finally, Keel et al. reported that eating-disordered boys experience great body dissatisfaction, depression, and perfectionism, as do eating-disordered females.

Language Bias

Anderson, Cohn, and Holbrook 2000) also pointed out that the descriptive words society uses to describe human body shapes are prejudiced against boys. For example, when describing a thin woman, people tend to use words like "svelte," "slim," and "willowy"; in describing a thin man, however, people tend to use words with a much more negative connotation, such as "pencil-neck," "stick," and "twerp." Based on the semantics, being a big man is preferable to being thin, because big men are referred to in less negative terms, such as "big daddy" "monster," and "hulk." Indeed, empirical studies suggest that being thin is hardly the ideal (Dittmar et al., 2000). LeDoux (1993) reported that 10.1% of the adolescent boys surveyed thought themselves to be too thin, compared with 4.2%

of the surveyed girls. Also, in a survey of 44 adolescent male football players and 30 adolescent male cross-country runners, Parks and Read (1997) found that 80% of the football players desired an increase in their weight, and 43% of the cross-country runners desired an increase in their weight. Boys, then, hear body types described in a pejorative way every day, and it does not take them long to figure out which type is the one to which they should aspire.

Coping Strategies

Adolescents construct their own methods for coping with body image disturbances. In his interviews with 20 college males, Weinke (1998) discovered three coping strategies that males used when faced with the ideal male image. The most harmful coping strategy, and, sadly, the most common, was the reliance on the popular muscular images for how a man should look. These young men saw the ideal male as realistic and either spent their time trying to achieve that image or berated themselves for not fitting it. A second coping strategy was the reformulation of the male body ideal; that is, boys modified the ideal and addressed it on their own terms. Although these young men may not have been totally consumed with thoughts of their own physical inadequacies, they still constructed the image to fit in their own schema and may have attempted to change themselves to fit this new image. The final coping strategy was the rejection of the ideal male image, which may have resulted in one's accepting himself for whom he currently was. Not surprisingly, this strategy was the most rare. When looking at these three strategies, one can see two common themes emerge. One is that males tend to view the image of the ideal man based on the images found throughout society. Even if they eventually reject the image, they still see the image as the ideal to some degree. The second theme, and perhaps even more damaging, is that these males tend to cope alone with their conflicts with the ideal male body image, without support.

STRATEGIES FOR SCHOOL COUNSELORS

School counselors are in a unique position to help adolescent boys address issues of body image that may be eroding their self-esteem and jeopardizing their physical and emotional health. Because of their presence in secondary schools, counselors may be pivotal people in increasing awareness among their peers of adolescent male body issues. In addition, they have access to parents and to individual boys who may be struggling with these issues. Several strategies for school counselors are described below.

Providing Individual Counseling

The first major hurdle to offering individual counseling to boys with body image disorders is the societal stigma for males seeking psychological assistance. Moreover, among males there is a greater taboo against revealing a body image problem because these problems largely have been associated with girls and women. Also, a boy might be feeling a sense of isolation, believing that he is "the only one" who feels this way about his body. Becoming an approachable, trustworthy adult in a male adolescent world is the first step toward providing individual counseling for boys with body image disorders.

Despite the limited opportunities some school counselors have for providing individual counseling, those who are able to utilize this option may find a cognitive behavioral approach useful (Pope et al., 2000). Rational emotive behavior therapy (Ellis, 1994, 1998, 1999) consists of confronting a client's faulty belief through a disputing intervention, replacing the faulty belief with a new belief and creating a new feeling in the client. Corer (2001) offered the following diagram to show how this form of cognitive behavioral therapy (CBT) works for the client:

A (activating event) [left arrow] B (belief) [right arrow] C (emotional and behavioral consequence)

[up arrow]

D (disputing intervention) [right arrow] E (effect) [right arrow] F (new feeling)

Let's return to the case of Brian. Imagine that Brian were to be caught for skipping class (A--activating event), and his response would be to "come unglued" and veil at the principal who asked him why he skipped class (C--emotional and behavioral response). The principal might then refer Brian to the school counselor. The counselor, through his or her listening skills and ability to draw Brian out, might discover Brian's negative feelings about his body. The counselor's realization that Brian's outburst had little to do with the principal's questions and more to do with Brian's unwillingness to admit his own insecurities about his body (B--belief) would be a significant aspect of applying CBT to this case. The counselor would then challenge Brian's beliefs about himself (D--disputing intervention) by asking Brian what proof he had that his body was terribly inadequate or by showing Brian images of the various body shapes that real men truly have. If the counselor can begin to change Brian's thinking about the way he looks, Brian might experience a new effect (E) and then a new feeling (F) about himself.

Of course, this example is a simplified version of what might happen, as it is very likely that a counselor would have to work with Brian for some time to get him to change his ideas about himself. However, such an approach would help Brian begin to get past the filtering (ignoring all the positive aspects about himself while choosing to focus on the negative) and polarized thinking he is doing, making it possible to create a change (Pope et al., 2000).

Providing Group Counseling

Group counseling in the schools also can be an effective way to change adolescent boys' opinions about their own bodies. Akos and Levitt (2002) suggest that the peer groups of middle- and high-school students can have strong positive effects on adolescents' self-concepts, including body image. Because many boys with body image disorders suffer in silence, learning that other boys in their peer group suffer from the same insecurities and receiving support from those peers can be quite beneficial to adolescent boys working within a single-gender support group.

An effective counselor facilitator is key to the efficacy of these groups. Rhyne-Winkler and Hubbard (1994) give several recommendations for counselors to make these groups a success, such as using materials that build self-esteem and maintaining current information on eating and body image disorders. For many adolescent boys, however, just knowing that an adult is aware of and cares about what they are going through can be the beginning of rebuilding a positive self-image.

Working with Parents

Arguably the most influential adults in a boy's life are his parents, who are likely to be the most accessible instruments for change in a boy's ideas about himself. School counselors can be important bridges between parents and their adolescents. Counselors can offer informational groups and support groups for the purpose of raising awareness among parents of the seriousness of body image problems for adolescent males. Pope et al. (2000) outlined the following simple interventions that parents can do when they suspect that their son might be suffering from a body image disorder. Counselors can assist parents with these interventions individually or in support groups.

First, counselors can alert parents to the value of listening to their sons. Many times personal insecurities emerge when least expected, such as when a parent and a son are doing an activity, together. It is when the boy is active that he might feel most comfortable about opening up. Second, parents can be intentional about talking to their sons about the prevailing and unrealistic male body ideals in society. They can let their sons know that having muscles is not the only way to be a real man. Third, counselors can caution parents to express their concerns to their sons without blaming. It is important for parents to let boys know that they care about their well-being but are not judging them from their mistakes. Fourth, counselors can remind parents to refrain from criticizing their sons' appearance. Counselors can help parents to see that although they want their sons to be healthy, putting undue pressure on them to conform to a certain body type can cause more harm than good. Fifth, although most parents want to offer their sons reassurance, it must be done wisely. Counselors can help parents remember not to dismiss their sons' concern about their bodies by saving, "Oh, I think you look great!" Such a response might keep the boy from opening up again, thinking that his parents just do not understand what he is experiencing. Finally, counselors can assist parents in helping their sons look for other sources of self: esteem. If a boy's only source of self-esteem is his body, parents need to point out other strengths that he has and encourage him to use those strengths in positive ways.

Overall, parental support and encouragement not to conform to societal images of the perfect man can do a lot to help a boy who might have a mild body image disorder. Having parents acting as the role models also speaks volumes to adolescent boys.

Consulting with Teachers and Coaches

Next to parents, teachers and coaches exert significant influence on adolescents. Often, however, they themselves may ascribe to some of the media-driven notions of what constitutes the "ideal" male physique. These adults have the potential to reinforce the cultural norm or to become open opponents of it. School counselors, by virtue of their role as both staff members and student advocates, have a special opportunity to influence the thinking and behavior of their colleagues. By conducting in-service and even pre-service training for teachers and coaches, school counselors can increase awareness of the growing body image disorders among adolescent males. Such training requires helping colleagues confront and address the ways in which they have accepted the prevailing views of masculinity as muscularity. Exposing the tactics of the media through a review of television commercials and magazine advertisements will help teachers and other school personnel understand the unrealistic goals they may set for themselves and, concomitantly, the adolescent boys they mentor. Engaging the support of school administrators and other officials will lend credibility to such training programs.

Organizing Consciousness-Raising Campaigns

Once there is grassroots acknowledgment of the body image disorder problem among adolescent males, and when teachers, coaches, and other school personnel commit themselves to providing alternative, healthy perspectives on body image, school counselors can spearhead a consciousness raising campaign in the entire school. Such a program would involve seeking volunteers from the community as well as colleagues to hold forums, to host informal focus groups, and potentially to infuse alternative ideas into the curriculum in health and physical education classes. Inviting local celebrities, athletes, and medical personnel to speak in school-wide assemblies to counter the existing cultural messages about the ideal body could be effective. Such a program could be the vehicle to break the silence about adolescent boys' body image problems. It could be a turning point for changing young people's unrealistic goals and attitudes about attaining the "ideal" in physical appearance.

Making Outside Referrals

Sometimes a boy's body image disorder can be severe enough that he needs to seek more intensive professional help. Family therapy is an important treatment option, given the known reciprocal impact of a family on disease and recovery (Anderson et al., 2000).

In addition, antidepressants prescribed by psychiatrists have been shown to be an effective treatment for bulimia nervosa. They can treat the symptoms of bulimia even if the patient is not depressed (Pope et al., 2000). Especially in the more extreme cases of body image disorders, a medical evaluation by a physician would be essential in the boy's healing process.

CONCLUSION

Boys in America are in a crisis over their bodies. Although it might be firmly entrenched in many minds that masculinity and muscularity go hand in hand, much can be done to put an end to that perspective. School counselors can be important catalysts for parents, educators, coaches, and other adults to become aware of the damaging effects that society's conception of the ideal male body image are having on adolescent boys. School counselors can provide work with individual boys on body image issues when time and circumstances permit this approach. They can provide information and support to parents as they work intentionally with their sons to combat the prevailing notions of masculinity in the culture. School counselors can function as consultants to teachers and coaches who may unwittingly participate in perpetuating the harmful and skewed beliefs about what it means to be "perfect man." School counselors can organize consciousness-raising campaigns in their schools to increase awareness of the problem and to minimize the stigma of boys seeking help. In cases of severe body image disorders, school counselors can make outside referrals to appropriate mental health providers. Moreover, school counselors can work to educate boys on what it truly means to be a man. Counselors can assist other adults in an adolescent boy's world to model the notion that being a man is about love, responsibility, tenderness, work, dependability kindness, and respect, all of which can be attained regardless of one's body shape. The sooner we can emphasize those important inner qualities over the outer appearance, the sooner we will see adolescent boys become happy, healthy, real men.

References

Akos, P. L., & Levitt, D. H. (2002). Promoting healthy body image in middle school. Professional School Counseling, 6(2), 138-144.

Anderson, A., Cohn, L., & Holbrook, T. (2000). Making weight: Men's conflicts with food, appearance. Carlsbad, CA: Gurze Books.

Cohn, L. D., & Adler, N. E. (1992). Female and male perceptions of ideal body shapes: Distorted views among Caucasian college students. Psychology of Women Quarterly, 16(1), 69-79.

Corey, G. (2001). Theory and practice of counseling and psychotherapy (6th ed.). Belmont, CA: Brooks/Cole.

Davis, C., Dionne, M., & Lazarus, L. (1996). Gender-role orientation and body image in women and men: The moderating influence of neuroticism. Sex Roles, 34(7/8), 493-507.

Dittmar, H., Lloyd, B., Dugan, S., Halliwell, E., Jacobs, N., & Cramer, H. (2000). English adolescents' images of ideal bodies. Sex Roles, 42(9/10), 887-915.

Eliot, A. O., & Baker, C. W. (2001). Eating disordered adolescent males. Adolescence, 36, 535-543.

Ellis, A. (1994). Reason and emotion in psychotherapy (Rev. ed.). Secaucus, NJ: Birch Lane.

Ellis, A. (1998). How to control your anxiety before it controls you. Secaucus, NJ: Birch Lane.

Ellis, A. (1999). How to make yourself happy and remarkably less disturbable. San Luis Obispo, CA: Impact.

Grogan, S., & Richards, H. (2002). Body image: Focus groups with boys and men. Men and Masculinities, 4(3), 219-232.

Hoyt, W. D., & Kogan, L. R. (2001). Satisfaction with body image and peer relationships. Sex Roles, 45(3/4), 199-215.

Keel, P. K., Klump, K. L., Leon, G. R., & Fulkerson, J. A. (1998). Disordered eating in adolescent males from a school-based sample. The International Journal of Eating Disorders, 23(2), 125-132.

Kolbe, R. H., & Albanese, P. J. (1996). Man to man: A content analysis of sole-male images in male audience magazines. Journal of Advertising, 25, 1-20.

Ledoux, S. (1993). Associated factors for self-reported binge eating among male and female adolescents. Journal of Adolescence, 16(1), 75-91.

Parks, P. S. M., & Read, M. H. (1997). Adolescent male athletes: Body image, diet, and exercise. Adolescence, 32(127), 593-602.

Phillips, J., & Drummond, M. (2001). An investigation into the body image perception, body satisfaction and exercise expectations of male fitness leaders: Implications for professional practice. Leisure Studies, 20(2), 95-105.

Philpott, D., & Sheppard, G. (1998). More than mere vanity: Men with eating disorders. Guidance and Counseling, 13(4), 28-33.

Pollack, W. (1998). Real boys. New York: Henry Holt & Company.

Pope, H. G., Olivardia, R., Gruber, A., & Borowiecki, J. (1999). Evolving ideals of male body image as seen through action toys. International Journal of Eating Disorders, 26, 65-72.

Pope, H. G., Phillips, K. A., & Olivardia, R. (2000). The Adonis Complex: The secret crisis of male body obsession. New York: The Free Press.

Rhyne-Winkler, M.C., & Hubbard, G.T. (1994). Eating attitudes and behavior: A school counseling program. School Counselor, 41 (3), 195-198.

Sondhaus, E. L, Kurtz, R. M., & Strube, M. J. (2001). Body attitude, gender, and self-concept: A 30-year perspective. The Journal of Psychology, 135(4), 413-429.

Weinke, C. (1998). Negotiating the male body. The Journal of Men's Studies, 6(3), 255-282.

Eric J. Stout is a teacher; and Dr. Marsha Wiggins Frame is an associate professor. They are with the University of Colorado at Denver: E-mail: [e-mail]