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Body Dysmorphic Disorder Techniques for Treating Obesessions with Body Perfection
Body Dysmorphic Disorder: Diagnosis & Treatment - 10 CEUs

Section 5
Body–gender Identity Incongruence

CEU Question 5 | CE Test | Table of Contents | Body Dysmorphia
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

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On the last track, we discussed three concepts of suicide related to BDD.  These three concepts related to BDD included:  suicidal thoughts; self-loathing; and self-deprecation and hallucinations.

On this track, we will examine three concepts related to gender and BDD.  These three concepts related to gender and BDD include:  similarities; differences; and femininity and masculinity.

3 Concepts of Gender and BDD

1. Similarities
The first concept of gender and BDD is similarities between the genders.  Surprisingly men and women appear similar in terms of most demographic features, and in terms of most clinical features, such as which body areas they dislike, BDD behaviors, severity of BDD symptoms, degree of impairment in functioning, and number of suicide attempts.  Men and women are also largely similar in terms of how many have comorbid psychiatric disorders, including anorexia, panic disorder, and depression. 

Usually, these disorders affect more women in the general population, which makes these findings interesting.  One explanation why men seem to have higher rates of comorbid disorders may be that these disorders come secondary to the BDD.  Another possible explanation is that the same underlying biological and psychological mechanisms that cause BDD also contribute to the depression that accompanies BDD.

"My teeth were hideous!"
Stacey, age 29, had been experiencing panic attacks that incited chest pains and shortness of breath.  I asked Stacey if she had had any of these symptoms prior to the onset of her BDD. 

Stacey said, "I began to get them about a month or two after I noticed that my teeth were smaller than other people’s.  I couldn’t smile and I believed that anyone looking at me thought my teeth were hideous!  When I did smile, I covered my teeth, and then I just looked idiotic.  Whenever I had to go to a social function with my husband, I would get panic attacks right before.  He’s so understanding, he would skip the function if I got too bad. I just don’t know how to calm myself down, I’ve never felt this before!" 

As you can clearly see, Stacey’s BDD had brought on a severe case of panic.  However, because this affliction had not occurred until after Stacey had begun to experience from BDD, I hypothesized, along with my other male clients, that the panic reacted secondarily to her BDD.  I also believed that by treating her BDD, the panic attacks would subside.  Think of your BDD clients.  Have you found that both women and men experience comorbid disorders equally?  Do you believe that these other disorders are secondary to BDD?

2. Differences
The second concept of gender and BDD is differences.  Generally, women are more likely to have an eating disorder whereas men experience more substance and alcohol abuse and are more likely to be single.  In addition, women are more likely to be concerned that their bodies are too large whereas men may be concerned that their bodies are not large enough.  This reflects cultural expectations of females to be small and petite and males to be large and intimidating. 

3. Unrealistic "Bar of Beauty"
All of the people who worried about excessive body hair were women, whereas all of those with genital concerns were men.  Have you noticed that these concerns almost directly relate to cultural expectations and standards of beauty? 

This raises the question whether the unrealistic "bar of beauty" and society’s emphasis on appearance are perhaps contributing to BDD clients’ symptoms.  Think of your BDD clients.  Have they ever expressed a feeling that they cannot live up to society’s standards?

Gary, age 38, had been concerned about his receding hair for six years, even though he still has an obviously full head of hair.  Gary stated, "I’m going to look like an old man by the time I’m forty!  What can I do!?  No creams or pills are working!  I can’t stop it!" 

Jenny, age 29, however, was concerned about her arm hair.  She stated, "I look like I’m wearing a muff.   I look like Robin Williams.  I shave it off, but it always shows.  No man will ever date me while I’m still looking like a gorilla!  I would try laser surgery, but it’s too expensive."  Although both these clients have concerns about their hair, one would prefer to get rid of it and another would prefer to keep it.  What differences have you noticed between your female and male clients?

Femininity and Masculinity
In addition to similarities and differences, the third concept regarding gender and BDD is femininity and masculinity.  In general, the concerns of BDD clients relate to their own perceived symbols of femininity and masculinity.  Female clients who believe that their breasts are too small may believe they are not feminine enough.  Male clients who obsess about their penis size also feel their masculinity is slighted by this defect.  Even female clients who obsess about their weight may feel too large and manly at their current weight.  If studied carefully enough, many BDD perceived defects relate to the client’s feelings of sexuality and what defines that sex.  Of course, what the client believes defines gender is only related to superficial appearances.  

Mia, age 27, believed that her perceived large size and smaller breast size made her look manly, even though she had always been told that she looked beautiful.  She stated, "I know no one would come out and say it, but I know I look like a man!  I’m huge and I don’t have any curves!  Why can’t I just be a woman for once?" 

I asked Mia what she believed a woman was.  She stated, "A woman is, of course, a person that has, well…female…stuff."  I then asked her, "But is it more than that?"  Mia stated, "Yea, of course.  Women are generally gentler and more understanding.  We may be a bit crazy sometimes, but it’s all for the greater good." 

I then stated, "What you just described to me is a definition without superficialities.  You didn’t talk about breast size and you didn’t talk about weight.  You talked about character.  Do you believe you fulfill these characteristics?"  She stated, "Yeah, I guess.  But I still don’t look like one."  Think of your Mia.  How is he or she using appearances to define their sexuality?  Do they actually believe their own definitions?

Technique:  Defining Sexuality
To help clients with defects that destroy their own sense of sexuality, I ask them to try the "Defining Sexuality" Exercise. 
1. I ask them to make a list of qualities that describe a man or a woman.  Gary wrote, "large, hairy, strong, has a penis, loves women, has a strong will, protects those he loves." 
2. I then asked Gary to cross off those characteristics that were superficial such as "large" and "hairy" and to concentrate on those qualities that are more characters than appearance. 
3. I then asked him if his receding hairline impaired him from loving women and protecting those he loves.  Gary stated, "Well, no.  It doesn’t.  I just don’t feel manly." 
4. I then stated, "But sometimes, what we feel and what is reality is not the same.  Do you agree?"  Gary stated, "Yes, I guess so.  That makes sense, it’s just hard for me to incorporate that into my life."  Think of your Gary.  Would her or she benefit from "Defining Sexuality?"

On this track, we discussed three concepts related to gender and BDD.  These three concepts related to gender and BDD included:  similarities; differences; and femininity and masculinity.

On the next track, we will examine three concepts of BDD in child clients.  These three concepts of BDD in child clients include:  characteristics; long-term consequences; and adolescence.

Body Dysmorphic Disorder: Recognizing and
Treating Imagined Ugliness

- Phillips, K. A. (2004). Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry, 1(3). p. 12-17.

Peer-Reviewed Journal Article References:
Baker, J. H., Higgins Neyland, M. K., Thornton, L. M., Runfola, C. D., Larsson, H., Lichtenstein, P., & Bulik, C. (2019). Body dissatisfaction in adolescent boys. Developmental Psychology, 55(7), 1566–1578.

Henrichs-Beck, C. L., & Szymanski, D. M. (2017). Gender expression, body–gender identity incongruence, thin ideal internalization, and lesbian body dissatisfaction. Psychology of Sexual Orientation and Gender Diversity, 4(1), 23–33.

Newman, S. (2020). Review of Clinical evolutions on the superego, body, and gender in psychoanalysis [Review of the book Clinical evolutions on the superego, body, and gender in psychoanalysis, by J. S. Lieberman]. Psychoanalytic Psychology, 37(1), 86–87.

van de Grift, T. C., Cohen-Kettenis, P. T., de Vries, A. L. C., & Kreukels, B. P. C. (2018). Body image and self-esteem in disorders of sex development: A European multicenter study. Health Psychology, 37(4), 334–343.

Online Continuing Education QUESTION 5
What are three concepts related to gender and BDD? To select and enter your answer go to CE Test.

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