On a recent break in Florence, walking among the chiselled marble sculptures of gods and demi-gods writhing in the coils of various mythical beasts, I began to feel unease. I don’t know if it was the sheer scale of the classical images of the male physique on display that was making me feel small, but I felt profoundly vulnerable.

A client of mine, let’s call him Paul, tells me that he wants ‘to be massive, so people will be scared of me’. ‘Why would you want people to be scared of you?’ I ask. I point out the glaringly obvious: that he is already extremely muscular.

But I know exactly how he feels. Paul first came to therapy because of his low mood and sexual promiscuity. It takes a while for his story to unfurl. He goes to the gym and lifts weights six times a week; he avoids aerobic exercise, in case he loses weight. He tells me that, however big he is, it’s never big enough.

Paul was relentlessly bullied in his childhood and youth. He describes his former self as ‘awkward, shy and a bit of a nerd, to be honest. I was so skinny it was painful’. He is embarrassed when he describes his school days, and starts to blush, laughing off the pain in his own words.

We talk about what it means for him to be bigger and more muscular. His use of the word ‘painful’ conjures up vividly his mental and emotional torture in feeling so frail and weak.

Despite all the time, effort and money he spends on enhancing his physical appearance, Paul is still too close to see the mismatch between his skinny, adolescent self-image and the reality today.

I ask him: ‘So, what have you achieved, to date, since you left school, that didn’t require you to be as muscular as you are – what hasn’t needed all that muscle?’ ‘I went travelling on my own… I got my degree… my own home and car,’ he tells me. ‘I’m doing well at work – I’ve had a few promotions… I have some really good friends, and I’m in a long-term relationship.’ He stops: ‘Although I don’t know if I would be, if I wasn’t as big as I am.’ My sense is that he’s not even half joking as he adds this.

Up until a few months ago, I would say I was bordering on having much the same problem. I was convinced that, despite appearing ‘big’ to other people, I was still the awkward, skinny boy I loathed throughout my adolescence and early 20s. I trained obsessively, six or even seven times a week, sometimes twice a day, in an attempt to eradicate him.

It wasn’t actually me that I hated; I liked what I saw as me – worldly, fairly intelligent, healthy, balanced and settled, with a great life. It was the image of me that I thought other people saw that I wanted rid of.

Muscle dysmorphic disorder

The fitness industry in the UK has grown from strength to strength in recent years. An estimated 9.2 million people now have a gym membership – that’s one in seven of us. Low-cost, no-contract, 24-hour access to gyms has mushroomed: achieving your fitness goals is now more affordable and easier than ever.

Alongside this expansion, muscle dysmorphic disorder (MDD) is becoming an increasingly common psychological problem among men.

What is driving so many young men to want to be bigger than they can possibly be?

The reasons are several, and very familiar to women. Men in the 21st century are constantly bombarded with images of the ‘perfect’ male physique, by hoardings, television, films and magazines. For women, the message is that to be successful you have to be young, slim and toned, with big breasts, perfect skin and a faultless complexion. For men, it’s much the same, without the breasts of course, except you also need a muscular body to be considered up to the job. And, again as women have pointed out since the dawn of post-war, second-wave feminism, the ideal is impossible for all but a very few to achieve and, in many cases, only then with chemical or cosmetic assistance.

As Pope and colleagues observe in their 2002 ground-breaking book on men and body obsession,1 the media gives out a contradictory message: men are judged by their appearance, and yet, by the standards of today’s doctored images of the super-male, few men, if any, can ever measure up.

Social media is awash with shirtless profile pictures, gym selfies, high-protein breakfasts and people ‘smashing’ exercise goals, tagged with a string of comments and ‘likes’. These instant media outlets send the message: ‘If you want what I have, you need to look like I do.’

However, here’s the catch: it’s mostly (if not all) fake. As Pope and colleagues point out, to get that degree of musculature requires more than hard work with weights; it takes steroids.1

When you see a very muscular, lean man, what you see is a chemically engineered shell created through prolonged use of steroids. I am not saying for a minute that the dedication and the hours of agony and effort at the gym aren’t real, but the motivation behind them that has created these men is fuelled by internal shame, insecurity and fear.

Pope and colleagues provide a measure of the cost:1 17% of their research sample said they would give up three years of their lives and 11% would give up five years to achieve their ultimate muscularity goal. When told that it might kill them, one replied: ‘Yeah, but you can die by getting hit by a truck, too.’ The responses these men use to rationalise their behaviour reflect the depth of their self-deception.

Masculinity and muscularity

Then there’s the radical change to men’s role, in the western world at least, arguably in symbiotic relation to changes in women’s status and role.

Women in the western world now have more equality with men than ever before. More women have more choices; they have education, careers, and social and financial independence. Men evolved with muscle to demonstrate their health, strength, status and general mate-ability. They needed to be strong to compete for the ‘fittest’ female, catch and kill the dinner, and repel enemies and predators.2 However, today’s world makes no such demands: the muscular, hunter-gatherer role is redundant.

A large part of the drive for muscularity is surely men’s attempt to revive their masculine identity.

‘What words come up for you when I say the word “masculine?”’ I ask Paul. ‘Muscular… strong… protective… in control, I suppose,’ he replies. This is where men are becoming confused. More and more, men are assuming muscularity equates with masculinity. It is evident that Paul is not ‘in control’, and his behaviour reflects this: his obsessive striving after hyper-muscularity is in control of him. Just as people with anorexia use laxatives, exercise and purging to control their weight, Paul’s steroid use and over-exercising is a means to conceal his emotional vulnerability behind his formidable image – but he can’t change his self.

As Tod and colleagues point out, wanting to look good and feel healthy are positive traits, but it is not healthy to compare yourself to the unattainable standards imposed by western society.3 Muscularity increases boys’ peer popularity; boys who have fewer friends are more likely to abuse steroids.3 As a skinny, awkward child who was bullied, I know that my self-worth and my self-image have been hugely affected to this day. My He-Man, GI Joe and Ninja Turtles toys – all very muscular – helped me imagine how I too could battle adversity, if only I could be bigger.

Childhood abuse and bullying results in feelings of shame, fear and helplessness that stay with us into adulthood. Paul’s muscularity can temporarily ease his feelings of physical vulnerability, but the internal emotional vulnerability is still present.

Paul has talked about steroids. He is clearly ashamed as he tells me how often he has done a ‘cycle’. His body language shouts ‘defeated’; he doesn’t look at me. ‘You seem quite embarrassed to tell me about your use of steroids. What’s making you feel so bad about it?’ I ask.

Paul’s answer doesn’t surprise me: ‘It’s cheating, isn’t it?’

‘So, it’s cheating… you’re being dishonest, then, would you say? Who are you being dishonest with?’

‘Myself… and everyone else. My girlfriend doesn’t even know I take gear [steroids]. She’d go mad – so I hide it from her.’

Paul wanted to leave the boy behind and become a muscular man, and his use of steroids made him just that – but burying his feelings under more muscle has just made things worse.

Steroid dependence

Cases of steroid dependence are on the rise. It’s been proposed that MDD should be classified as an addiction, precisely because the person gets locked into maintenance behaviours that may cause long-term harm.4 Like all addictions, it’s circular: men start taking steroids to boost their musculature, but can’t cope with the muscle loss, reduced libido and depressive episodes when they come off, so go back on steroids to relieve these symptoms of withdrawal.

The more testosterone a man has in his body, the higher their sex drive, which can lead to compulsive and risky sexual behaviour. Paul has been with his girlfriend for over two years, yet he frequently sleeps with other women, which leads to more feelings of guilt and shame, and compounds his already distressed state and feelings of worthlessness and self-loathing. Then he punishes himself with a gruelling workout.

He also binges on online pornography. He tells me: ‘The only happiness I get is from watching porn.’ But, after five hours of ‘trawling’, he feels angry and guilty about it.

‘This guilt that you feel – is it guilt because you’ve been unfaithful or is it guilt because you feel you’ve let yourself down?’ I ask. ‘Both,’ he says.

‘So you feel guilty for cheating on your girlfriend, and guilty for letting your compulsive behaviour get the better of you, and you feel dishonest for taking steroids… It sounds like there’s a lot of behaviour here that’s covering up the real you. Do you know who you want to be?’

‘Not this,’ he says, with genuine anger.

He tells me he compares himself with the actors in the porn movies he watches. But the constant comparison has led to performance anxiety and erectile dysfunction, for which he now buys Viagra online. He wants to ‘show [his girlfriend] that I’m good in bed and keep her happy. I want her to find me attractive’.

‘So, you’re saying the better in bed you are, the more attractive that makes you... And the sex you see in the porn is the sex that your girlfriend actually wants?’ I ask.

‘Well, probably not, no. In fact, I’ve accidentally hurt her a few times, and that just made me feel even worse – I can’t seem to get it right.’

‘And who do you need to get it right for? If your girlfriend doesn’t want the sex you’re performing because you hurt her, it sounds like you’re trying to prove something to yourself,’ I venture.

He says he takes Viagra ‘because I don’t want her to think any less of me if I can’t get it up, and then I think, if I can’t do it, she will go elsewhere, and, if I do manage to get it up and do it and it’s shit, she’ll leave me anyway – so I can’t win’.

‘What if it was the other way around and occasionally you weren’t satisfied in bed – would you think any less of her?’ I ask him. ‘Of course not – I love her to bits.’

Masculine and muscular

I know from my own experience and from working with people like Paul that men find MDD a difficult subject to bring up. Many will deny it is a problem, and deny they have used any ‘chemical help’ to achieve their current physique. At my local gym, I see a multitude of young men desperately trying to gain validation and acceptance through their muscularity. And, one day, I finally saw myself. That is when my own recovery truly began, and I realised I am more than a transient physique. But there’s a lot of men out there who haven’t reached that place.

Fundamentally, the one thing we men are forgetting is that masculinity isn’t about muscle. It is OK to be OK. Not so long ago, the most glamorous men in Hollywood were (by today’s standards) wimps. Yet today, despite the emphasis on being masculine and muscular, men are also more open to looking after their health and their appearance. Moisturising and male grooming are no longer regarded as effeminate; they’re celebrated by both sexes.

The simple offer of open, non-judgmental dialogue and empathy can make a world of difference to men, like Paul, who are struggling to find an identity in today’s testosterone-fuelled, competitive, judgmental world.


Noah Sisson-Greene is a second-year diploma student in therapeutic counselling at The Manchester College. He has an interest in LGBTQIA issues and body dysmorphia, and is a qualified meditation teacher.


1. Pope H, Phillips K, Olivardia R. The Adonis complex: how to identify, treat and prevent body obsession in men and boys. New York: Touchstone; 2002.
2. Gray J, Ginsberg R. Muscle dissatisfaction: an overview of psychological and cultural research and theory. Washington, DC: American Psychological Association; 2007.
3. Tod D, Edwards C, Cranswick I. Muscle dysmorphia: current insights. Psychology Research and Behavior Management 2016; 9: 179–188.
4. Foster AC, Shorter GW, Griffiths MD. Muscle dysmorphia: could it be classified as an addiction to body image? Journal of Behavioral Addictions 2015; 4(1): 1–5.
5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed). Washington, DC: APA; 2013.
6. Pope CG, Poe HG, Menard W, Fay C, Olivardi R, Phillips KA. Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body Image 2005; 2(4): 395–400.

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