The gym is constantly on Dashiell Frederickson's mind. The 16-year-old works out religiously every day, sometimes for up to three hours a day.
"The gym is all I can think about during the day," Frederickson said. "I wake up, I'm thinking about the gym. I'm brushing my teeth, I'm thinking about the gym … and once I'm finally at the gym, I'm kind of set and I'm happy."
Despite all this effort to hone his physique, despite his friends telling him how good he looks, when Frederickson looks in the mirror, he thinks he looks "horrible."
Body dissatisfaction among young people is on the rise, and clinicians like Dr. Jason Nagata say it's a trend that's starting to affect more boys. That's challenging a long-held tendency in medicine — and more broadly by society — to associate body image concerns mainly with girls.
Nagata, an eating disorder researcher at the University of California, San Francisco, says negative body image attitudes in boys often stem from the feeling that they aren't muscular enough. A small share of those young men develop an obsession with getting bigger and more muscular — also called bigorexia.
"It occurs when someone is preoccupied or even obsessed with the idea that they don't have enough muscularity," Nagata said. "In many cases, an individual's build is actually normal or even objectively muscular."
Frederickson doesn't see himself that way, and hasn't been diagnosed with bigorexia. He says he has "body dysmorphia," though he's never been diagnosed with that either.
The discovery of bigorexia
Bigorexia was first described in a 1993 case report of nine "large and muscular" bodybuilders who became so preoccupied with working out that they "declined social invitations, refused to be seen at the beach or wore heavy clothes" during the summer, fearing they looked too small in normal clothing.
A few dozen research articles were published after the original report, but bigorexia remained relatively understudied until recently, according to Nagata. While it's hard to measure how many boys have bigorexia, eating disorders in young men are a growing problem.
"For many people, the fact that boys and men have body image pressures is completely not on their radar," Nagata said. "When we get referrals for boys and men with muscle dysmorphia, there's often a long delay in referral and diagnosis."
Three major pressures — family, peers and the media — contribute to the rise of muscle dysmorphia and men's desire to build muscle. Across multiple studies, the last variable is the most significant predictor of muscle dysmorphia.
Frederickson's social media feeds are filled with content from bodybuilders whose idealized Greek-god bodies remind him of what he'd like to look like one day.
"My friends were sending me videos on Instagram, and they were like, 'Oh, this guy looks insane,'" Frederickson recalled. "I started to compare myself with these adults. It kind of made me lose a lot of self-confidence."
George Mycock experienced symptoms of bigorexia in his early 20s and now studies the condition as a graduate student at the University of Worcester in England. He points to the inherent design of social media as an important driver of these trends.
"You tend to gain more social and monetary capital if the images and stuff you're putting out are more extreme," he said. "And then, so much more extra extreme body ideals get put out."
Bulking and cutting to sculpt perfect muscles
The obsession with muscularity drove Mycock to the edge as he became fixated on working out. During this period, he cycled through what bodybuilders term the "bulking" phases — where he ate more to build muscle — and "cutting" phases, cycles of trying to lose weight to help bring out muscle definition. He'd weigh every meal to avoid gaining any weight, forcing himself to vomit and spiraling into suicidal thoughts.
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All of his training — it wasn't enough. "I just felt like my body could be a symbol of how masculine I was," Mycock said.
Physically, the condition can be invisible, in contrast to disorders like anorexia — where patients can have a very low body weight and look visibly thin. That's why when bigorexia was first described, it was called "reverse anorexia."
"It's really hard to tell if someone has muscle dysmorphia just by looking at them," Nagata said. "There may be people who are from a range of body sizes, weights and shapes who experience muscle dysmorphia."
Those with the condition are more at risk of disordered eating, steroid use and suicidal ideation. When disordered eating becomes severe, patients can be hospitalized. And a growing share of those patients are now boys, according to a longitudinal study in Canada. The authors of that study say there's a "pressing need" to educate clinicians about the trend.
Who's affected remains a mystery
Nagata estimated that a third of teenage boys in the U.S. are trying to bulk up. But how many go on to develop bigorexia is harder to pin down.
That challenge stems from a lack of awareness of the condition, which was first added to the DSM — a handbook used by clinicians to diagnose mental health conditions — in 2013. Diagnosing young men with bigorexia is also difficult because they're less likely to seek out help and experts disagree on how to diagnose it.
When bigorexia was first added to the DSM, it was classified as a body dysmorphic disorder — a condition causing someone to obsess over a perceived flaw in their appearance — which doesn't account for the disruptive eating seen in bigorexia. That discrepancy complicates diagnosis.
For instance, someone showing signs of an eating disorder can't be diagnosed with bigorexia because eating disorders and body dysmorphic disorders are considered mutually exclusive. That's why, in a recent paper, Nagata argued for bigorexia to be recognized as an eating disorder.
While researchers continue to debate this distinction, it's clear that certain groups, like transgender men, are more at risk.
"Biologically, they may have appearance factors that are more feminine, and then they're trying to change that so that they feel like they're in a more masculine body," Nagata said. "There's added sort of hoops that they have to go through to get this sort of muscular build."
A dark side to exercise
Frederickson admitted that he thinks about his physique nearly every day, calling it mentally exhausting. "You just kind of tell your brain to shut up," he said. "But it just gets annoying telling yourself, 'You need to look better. You need to cut. You need to bulk. You need to stay at where you are.'"
Despite these pressures, the teen feels supported by his family and medical providers, and has noticed exercise has had positive effects. "I feel a lot more confident with myself. It's easier to run around, easier to do things. I'm not out of breath as quickly."
But this doesn't ring true for all of his peers, some of whom he said have started using steroids to "look better as fast as possible." "They tell me they just hated what they looked like and they wanted to look better quick."
Though exercise is beneficial — and many kids in the U.S. aren't getting enough of it — the dangers of bigorexia can be life-threatening. But public health messaging often fails to mention how much exercise is too much for kids. Mycock is on a mission to change that.
"I always talk about the fact that people refer to exercises like the wonder drug," Mycock said. "Like with every other drug … there's a tab that talks about side effects and addiction issues."
"It's not about saying that exercise and diet are bad for you. It's just that too much of it or overdependence on it — or when it becomes your whole identity — it can become a problem."
Michal Ruprecht is a Stanford Global Health Media Fellow.
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