Muscle dysmorphia: what about transgender people?

Use of photo filters is associated with muscle dysmorphia symptomatology among adolescents and young adults

It has been documented in the literature that the use of photo filters to alter one's appearance may negatively impact body image and increase the risk for thinness-oriented disordered eating behaviors. However, the prior research has neglected to investigate the association between use of photo filters and muscle dysmorphia symptomatology, which was the aim of this study. Data from the Canadian Study of Adolescent Health Behaviors (2022; N = 912), a national study of adolescents and young adults in Canada, were analyzed. Linear regression analyses revealed that the use of photo filters was associated with greater muscle dysmorphia symptomatology, including total symptomatology and Appearance Intolerance, among the overall sample. Gender significantly moderated the association between photo filter use and muscle dysmorphia symptomatology, whereby boys and young men, compared to girls and young women, who reported photo filter use had greater Drive for Size and Functional Impairment symptomatology. Findings expand prior research by emphasizing that photo filter use is related to muscularity-oriented body image concerns and behaviors. Future research is needed to elucidate the mechanisms that underpin this association.

Losing, gaining, or staying the same: how do different weight change attempts relate to muscle dysmorphia and eating disorder symptoms across genders?

Adolescents and young adults are at heightened risk for eating disorder (ED) and muscle dysmorphia (MD) symptoms; yet, these symptoms and their relationships to harmful behaviors may also vary by gender. Thus, this study examined: 1) the prevalence of attempts to lose, gain, or maintain the same weight across gender identities, 2) purposes of weight change attempts, and 3) relationships between weight change attempts and ED and MD symptoms across cisgender men, women, and transgender and gender expansive (TGE) youth. 940 adolescents and young adults (57.4% cisgender women, 33.8% cisgender men, 8.8% TGE) completed questionnaires about weight change attempts, ED and MD symptoms. Women and TGE individuals attempted to lose weight more often than men, while men attempted to gain weight more often. All genders endorsed weight loss and gain attempts for different purposes. Weight loss attempts related to ED symptoms and appearance intolerance, whereas weight gain attempts related to MD symptoms across genders. In women, all weight change attempts related to greater functional impairment due to exercise. Findings highlight the need for tailored interventions to address desires to change one's body and underscore the harmful effects of weight change attempts across genders.

Experiences of body image in the gender non-binary community: A qualitative analysis

Body image concerns are prevalent within transgender communities - many transgender people engage in disordered eating to suppress or accentuate secondary sex characteristics and reduce gender dysphoria. However, this research has mostly been conducted with binary transgender people. Here, we examine how non-binary people experience and relate to their bodies. Semi-structured one-on-one interviews were conducted with 13 gender non-binary individuals living in Australia. Photo elicitation techniques were utilised, and the transcribed interview data were analysed using reflexive thematic analysis. Six themes were identified: Expansive Understandings of Body Image, Body Image can be Linked to Gender Dysphoria, Cultivating a Preferred Body can Lead to Gender Euphoria, Appreciating Diversity in Non-Binary Body Ideals, The Androgynous Body Ideal is not Universally Accepted, and Experiencing the Body as Functional rather than Aesthetic. The present findings highlight the diversity of experiences of body image for non-binary people. The non-binary concept of body image was found to be expansive, stressing various physical attributes involved in social gender recognition and physiological sources of gender dysphoria. Some participants valued gender-affirming medical intervention, others were accepting of their bodies as they are, attributing their body confidence to the process of affirming their non-binary gender.

Effect of gender identity on the association between gender dysphoria and suicidality via appearance anxiety among transgender and gender-diverse young people: moderated mediation study

BACKGROUND

Gender dysphoria is associated with suicidality among transgender and gender-diverse (TGD) people. Gender dysphoria also results in a stress on appearance.

AIMS

The objectives of this study were to examine: (a) whether appearance anxiety mediates the effect of gender dysphoria on suicidality; and (b) whether gender identity moderates the mediating effect of appearance anxiety.

METHOD

A total of 117 769 college and university students were recruited in this cross-sectional study from Jilin Province, China. After screening based on participants' gender identity, 2352 TGD young people (aged from 15 to 25 years) were divided into three subgroups: female to male (FTM), male to female (MTF) and non-binary. Self-report inventories measured gender dysphoria, suicidality and appearance anxiety. A structural equation model was run to examine the relationships among TGD gender identity, gender dysphoria, appearance anxiety and suicidality.

RESULTS

Among TGD young people, gender dysphoria was significantly positively associated with suicidality (β = 0.15, 95% CI = 0.11-0.18, P < 0.001). Appearance anxiety partially mediated the association between gender dysphoria and suicidality (β = 0.07, 95% CI = 0.05-0.08, P < 0.001). Gender identity moderated the mediating effects: compared with individuals with FTM identity, among those with MTF and non-binary identities, gender dysphoria showed stronger positive effects on appearance anxiety, and appearance anxiety showed greater effects in mediating the association between gender dysphoria and suicidality.

CONCLUSIONS

Among TGD young people, gender dysphoria is significantly associated with suicidality via appearance anxiety, with gender identity moderating the mediating effects. Diverse treatments should consider the heterogeneity of TGD subgroups, with the aim of limiting the tendency of gender dysphoria to trigger appearance anxiety, thus further buffering against the risk of suicide.

Physical activity among transgender individuals: A systematic review of quantitative and qualitative studies

Transgender individuals face stigma, discrimination, and other barriers impacting their ability to engage in physical activity (PA). We aim to review current literature on PA among transgender individuals. A systemic literature search of research studies from 2010-2023 was conducted. Studies must have reported a measure of PA and gender, be original research, and focus on transgender participants' PA. Rates of PA for transgender individuals were lower compared to cisgender or sexual minority individuals. Transgender women were less likely to engage in PA than other groups. Qualitative results suggest transgender oppression, stigma, discrimination, body image, unwelcoming environments (gyms, locker rooms, swimming pools), and the dichotomous structure of sport contribute to lower rates of PA among transgendered individuals. Disparities in PA for transgender individuals exist. Policy, environment, and system changes are needed to reduce transgender stigma in sport and PA settings. Current legislation is being developed and implemented in the United States regarding the place of transgender individuals in sport and PA. These results should inform public discourse on the topic.

Body Image Among Sexual and Gender Minorities: An Intersectional Analysis

Body image is consequential for overall well-being and has a complex relation to gender. Sexual and gender minority (SGM) individuals develop body image amid intersecting systems of oppression, such as sexism, cisnormativity, heteronormativity, and gender binary pressures. This study used an intersectionality framework to examine how various aspects of gender identification (cis/trans, binary/nonbinary, woman/man identification) related to body image differences among SGM individuals. We also assessed whether identification with conventionally masculine and feminine personality traits predicted body image. We used one-way and two-way ANOVAs and linear regressions to analyze two indicators of body image (body appreciation and drive for muscularity) in a sample of 643 SGM individuals (148 sexual minority (SM) cis women, 171 trans women, 121 SM cis men, 43 trans men, 160 nonbinary individuals). Results implicated cisnormativity as an influential and hierarchical force for body image, although woman/man and binary/nonbinary identification also played roles in group differences. With a few exceptions, masculine but not feminine trait identification significantly predicted body appreciation and drive for muscularity, indicating a complicated association with overall body image. These findings underscore the value of an intersectional lens for analyzing how broad social forces may manifest in individual-level body image for SGM individuals.

The primacy of ocular perception: a narrative review on the role of gender identity in eating disorders

BACKGROUND

Phenomenological research has enriched the scientific and clinical understanding of Eating Disorders (ED), describing the significant role played by disorders of embodiment in shaping the lived experience of patients with ED. According to the phenomenological perspective, disorders of embodiment in ED are associated with feelings of alienation from one's own body, determining an excessive concern for external appearance as a form of dysfunctional coping. The purpose of the present narrative review is to address the role of gender identity as a risk factor for EDs in the light of phenomenological approaches.

METHODS

Narrative review.

RESULTS

The current study discusses the interplay between perception, gender identity, and embodiment, all posited to influence eating psychopathology. Internalized concerns for body appearance are described as potentially associated with self-objectification. Furthermore, concerns on body appearance are discussed in relation to gendered social expectations. The current review also explores how societal norms and gender stereotypes can contribute to dysfunctional self-identification with external appearances, particularly through an excessive focus on the optical dimension. The socio-cultural perspective on gender identity was considered as a further explanation of the lived experience of individuals with ED.

CONCLUSIONS

By acknowledging the interplay between these factors, clinicians and researchers can gain a deeper understanding of these disorders and develop more effective interventions for affected individuals.

LEVEL OF EVIDENCE

Level V narrative review.

Body Image and High-Risk Weight and Shape Control Behaviors Among Transgender and Nonbinary Young Adults: The Role of Sexual Assault

Purpose: Transgender and nonbinary (TNB) populations experience disproportionate rates of sexual assault. Despite evidence from cisgender samples linking sexual assault exposure to body image concerns and disordered eating behaviors, such as weight and shape control behaviors (WSCBs), little is known about these relationships in TNB people. The purpose of this study was to assess associations among past-year sexual assault exposure, body areas satisfaction, body weight esteem, and high-risk WSCBs in a sample of TNB young adults. Methods: A sample of 714 participants completed a cross-sectional online survey. Multivariable linear and logistic models were fit to determine associations between constructs of interest. Natural effects mediation analyses assessed for potential mediation of the relationship between sexual assault and WSCBs by body areas satisfaction and body weight esteem. Analyses were stratified by three gender identity categories. Results: Past-year sexual assault exposure was associated with significantly decreased body areas satisfaction, but only for nonbinary participants. No significant association was found between sexual assault and body weight esteem. Sexual assault was associated with significantly increased risk for WSCBs across gender identity categories. No mediation of these relationships by body areas satisfaction and body weight esteem was observed. Conclusion: Findings support clinical consideration of WSCBs in TNB survivors of sexual assault. Results suggest that multiple factors, including body image and sexual assault, may contribute separately to disordered eating behaviors in TNB young adults.

Muscle dysmorphia symptomatology among a national sample of Canadian adolescents and young adults

The aim of this study was to describe muscle dysmorphia (MD) symptomatology among a large, diverse, and national sample of adolescents and young adults in Canada. Data from the Canadian Study of Adolescent Health Behaviors (N = 2256) were analyzed. MD symptomatology was assessed using the Muscle Dysmorphic Disorder Inventory (MDDI). Men (mean [M] = 33.9, standard deviation [SD] = 8.6) reported significantly greater overall MD symptomatology compared to women (M = 30.1, SD = 7.3) and transgender/gender non-conforming (TGNC; M = 31.5, SD = 7.6) participants. Similarly, the prevalence of clinical MD risk was also highest among men (25.7 %). In regression analyses, participants who identified as South Asian (B 1.97, 95 % confidence interval [CI] 0.41, 3.52) or Middle Eastern (B 2.92, 95 % CI 0.50,5.35), compared to White participants, or identified as gay or lesbian (B 2.65, 95 % CI 1.19, 4.10), compared to heterosexual participants, had greater MD symptomatology. Findings are the first to describe the MD symptomatology among Canadian adolescents and young adults. Health care and public health professionals should be aware of the overall high occurrence of MD symptomatology in this sample, and future research is needed to continue to describe MD among Canadian young people.

Psychometric validation of the Muscle Dysmorphic Disorder Inventory (MDDI) among U.S. transgender men

Muscle dysmorphia (MD) is characterized by a pervasive belief or fear of insufficient muscularity and an elevated drive for muscularity, representing the pathological and extreme pursuit of muscularity. Psychometric properties of one of the most widely used measures of MD symptoms-the Muscle Dysmorphic Disorder Inventory (MDDI)-have yet to be evaluated in transgender men despite emerging evidence suggesting differential risk for MD symptoms in this population. In this study, we assessed the psychometric properties of the MDDI in a sample of 330 transgender men ages 18-67 years who participated in a large-scale national longitudinal cohort study of sexual and gender minority adults in the U.S. Using a two-step, split-sample approach, an initial exploratory factor analysis supported a three-factor structure and a subsequent confirmatory factor analysis of a re-specified three-factor model demonstrated good overall fit (χ2/df = 1.84, CFI =0.94, TLI =0.92, RMSEA =0.07 [90% CI =0.05,.09], SRMR =0.08). Moreover, results supported the internal consistency and convergent validity of the MDDI subscales in transgender men. Findings inform the use of the MDDI among transgender men and provide a foundation to support further work on the MDDI and MD symptoms among gender minority populations.

Psychometric evaluation of the muscle dysmorphic disorder inventory (MDDI) among gender-expansive people

PURPOSE

Muscle dysmorphia is generally classified as a specific form of body dysmorphic disorder characterized by a pathological drive for muscularity and the preoccupation that one is too small or not sufficiently muscular. The majority of research on the condition has been conducted in cisgender men with a paucity of literature on gender minority people, a population that is at risk for muscle dysmorphia. One of the most widely used measures of muscle dysmorphia symptoms, the Muscle Dysmorphic Disorder Inventory (MDDI), has not been psychometrically validated for use in gender minority samples, the aim of the present study.

METHODS

We evaluated the psychometric properties of the MDDI in a sample of 1031 gender-expansive individuals (gender minority people whose gender identity differs from that assumed for their sex assigned at birth and is not exclusively binary man or woman) aged 18-74 who were part of The PRIDE Study, a large-scale, U.S., longitudinal cohort study.

RESULTS

Using a two-step, split-sample exploratory and confirmatory factor analytic approach, we found support for the original three-factor structure of the measure. The subscales showed adequate internal consistency, and convergent validity was supported based on significant associations of the MDDI subscale scores with theoretically related scores on a widely used measure of disordered eating.

CONCLUSIONS

These findings provided novel support for adequate psychometric properties of the MDDI in a sample of gender-expansive individuals, facilitating the use of this measure in future research on muscle dysmorphia in this understudied and at-risk population.

Appearance and performance-enhancing drugs and supplements, eating disorders, and muscle dysmorphia among gender minority people

OBJECTIVE

Appearance and performance-enhancing drugs and supplements (APEDS) can be used to enhance muscle growth, athletic performance, and physical appearance. The aim of this study was to examine the lifetime use of APEDS and associations with eating disorder and muscle dysmorphia symptoms among gender minority people.

METHOD

Participants were 1653 gender minority individuals (1120 gender-expansive [defined as a broad range of gender identities that are generally situated outside of the woman-man gender binary, e.g., genderqueer, nonbinary] people, 352 transgender men, and 181 transgender women) recruited from The Population Research in Identity and Disparities for Equality Study in 2018. Regression analyses stratified by gender identity examined associations of any APEDS use with eating disorder and muscle dysmorphia symptom scores.

RESULTS

Lifetime APEDS use was common across groups (30.7% of gender-expansive people, 45.2% of transgender men, and 14.9% of transgender women). Protein supplements and creatine supplements were the most commonly used APEDS. Among gender-expansive people and transgender men, lifetime use of any APEDS was significantly associated with higher eating disorder scores, dietary restraint, binge eating, compelled/driven exercise, and muscle dysmorphia symptoms. Any APEDS use was additionally associated with laxative use among gender-expansive people. Among transgender women, use of any APEDS was not significantly associated with eating disorder or muscle dysmorphia symptoms.

DISCUSSION

APEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in gender-expansive people and transgender men, thus highlighting the importance of assessing for these behaviors and symptoms among these populations, particularly in clinical settings.

PUBLIC SIGNIFICANCE

This study aimed to examine APEDS use among gender minority people. We found that 30.7% of gender-expansive (e.g., nonbinary) people, 45.2% of transgender men, and 14.9% of transgender women reported lifetime APEDS use, which was associated with eating disorder and muscle dysmorphia symptoms in transgender men and gender-expansive people. Clinicians should assess for these behaviors in gender minority populations.

"Having a non-normative body for me is about survival": Androgynous body ideal among trans and nonbinary individuals

The present study focused on trans and nonbinary (TNB) individuals who have an androgynous or non-stereotypical body ideal, with attention to how their body ideal is conceptualized and maintained. Data were collected online from 76 TNB individuals. Based on responses to two open-ended prompts, a two-tiered analysis was conducted. First, thematic analysis was used to develop four central themes describing the way TNB individuals conceptualized their androgynous body ideal: 1) Attaining Neutrality and De-Categorizing Gender; 2) Disaggregating Gender Expression; 3) Managing Gender Dysphoria; and 4) Achieving Authenticity. Second, content analysis was used to document 12 behaviors engaged in or actions taken for the purpose of approaching or maintaining an androgynous or non-stereotypical body ideal. These were grouped into 3 main categories: gender expression (clothes, hair, make-up, body modifications), body shape (weight, muscularity, eating/diet), and sex characteristics (hormone therapy, body hair, vocal, chest, genitals). Results of the present study expand the current body ideal literature by including TNB narratives and by focusing specifically on the ways an androgynous body ideal is conceptualized and maintained. Research and clinical implications are discussed.

Review: Prevalence of Addictions among Transgender and Gender Diverse Subgroups

We conducted an analysis of the prevalence of substance and behavioral addictions across different transgender and gender diverse (TGD) subgroups. We performed a scoping review using MEDLINE and Google Scholar databases and examined 12 addictions, including alcohol, nicotine, cannabis, illicit drugs, gambling, eating/food, internet, sex, love, exercise, work, and shopping. We presented prevalence rates for each addiction as a function of an individual’s gender identity (stratified into transgender females, transgender males, and gender nonconforming), and used cisgender women and men as reference groups. We included 55 studies in our final analysis, the majority of which investigated substance use disorders among TGD subgroups. Overall findings indicated that substantial differences in substance use exist among US TGD subgroups. There were far fewer publications that examined the prevalence of behavioral addictions across TGD subgroups. However, despite limited research in this area, findings still suggest that notable differences in behavioral addictions may exist between individual TGD subgroups. The conclusions of our review may provide clinicians with a better ability to screen for and treat at-risk individuals within the TGD community.

Community norms of the Muscle Dysmorphic Disorder Inventory (MDDI) among gender minority populations

PURPOSE

Representing the pathological extreme pursuit of muscularity, muscle dysmorphia (MD) is characterized by a pervasive belief or fear around insufficient muscularity and an elevated drive for muscularity. Despite evidence of heightened body image-related concerns among gender minority populations, little is known about the degree of MD symptoms among gender minorities, particularly based on Muscle Dysmorphic Disorder Inventory (MDDI) scores. The objective of this study was to assess community norms of the MDDI in gender-expansive people, transgender men, and transgender women.

METHOD

Data from participants in The PRIDE Study, an existing study of health outcomes in sexual and gender minority people, were examined. We calculated means, standard deviations, and percentiles for the MDDI total and subscale scores among gender-expansive people (i.e., those who identify outside of the binary system of man or woman; n = 1023), transgender men (n = 326), and transgender women (n = 177). The Kruskal-Wallis test was used to assess group differences and post hoc Dunn's tests were used to examine pairwise differences.

RESULTS

Transgender men reported the highest mean MDDI total score (30.5 ± 7.5), followed by gender-expansive people (27.2 ± 6.7), then transgender women (24.6 ± 5.7). The differences in total MDDI score were driven largely by the Drive for Size subscale and, to a lesser extent, the Functional Impairment subscale. There were no significant differences in the Appearance Intolerance subscale among the three groups.

CONCLUSIONS

Transgender men reported higher Drive for Size, Functional Impairment, and Total MDDI scores compared to gender-expansive people and transgender women. These norms provide insights into the experience of MD symptoms among gender minorities and can aid researchers and clinicians in the interpretation of MDDI scores among gender minority populations.