Of Bears and Twinks: Weight Loss Issues for Gay Men in Therapy

Gay Men’s Culture

As a psychotherapist who has specialized in working with gay men for the past 26 years, I know that part of gay men’s culture is an emphasis on a youthful, lean, muscular physique.  The sentiment is pervasive, and competitive — sometimes good-naturedly, sometimes aggressively and cruelly.

Gay men’s culture has identified the athletic physique as “the ideal”.  While it’s reasonable to say that the gay community can take this idea too far, it’s also true that many physicians often tell their patients upon exam if and when they need to lose weight.  The health benefits of maintaining a recommended range of body weight (or BMI) for any person’s age and build are countless (lowering the risk of heart disease, diabetes, stroke, stenosis, sciatica, joint problems, mood disorders, long-term health expenses, longevity, etc.).  In this way, gay men who are overweight get pressure to address and change their bodies from two fronts:  the socio-cultural, and the medical.  The pressure they feel to transform their physical presentation can be intense — and in a way that straight men (and straight women) do not face to the same degree.

Gay male culture (usually of big cities, like LA, New York, Fort Lauderdale, Dallas, etc., but also smaller towns, since the advent of the Internet and widespread media images) “demands” adherence to the ideal body image – or makes men suffer the consequences of being socially ostracized (at least in some circles).  This is colloquially called “Body Fascism”, and involves the idea of  judging a gay man’s inherent worth by how well his   physique matches the ideal — giving status to those men with good physiques (and possibly no other attributes), and stigma to those who are overweight (who might have myriad other merits).

Disorders Risk

This kind of pressure can put patients at risk of developing disorders cataloged in the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5 (American Psychiatric Association, 20013).  These include Anorexia Nervosa (which, by the way, has the highest mortality rate of all mental disorders) (Keel, et. al, 2003) and Bulimia (which affects gay men with more prevalence than straight men) (Blashill, 2010).

There is also the risk of developing Body Dysmorphic Disorder (or, more precisely referred to in recent times as “Muscle Dysmorphia”) (Morgan, 2008), or even just casually called “Bigorexia”.  I have noticed in many years of practice that there even can be an exacerbation of Major Depressive Disorder that comes from the hopelessness clients express that they feel they will never achieve a kind of hyper-prestigious social status as a result of their perceived “inferior” physical shape.  This must be addressed and put into more realistic terms through cognitive therapy that liberates the client from these perceptions.

However, even if a gay man can make peace with himself in having an “imperfect” physique, and buck the gay cultural demand (with a healthy self-assertion, or even defiance), the health risks of carrying extra weight remain, along with undermining a healthy aging process for the duration of their lives.  It’s a dilemma that many of my gay male clients have faced over the years.

Relationships

Being overweight also can be an unspoken issue in a relationship, where, away from the client, his partner might privately express dissatisfaction and loss of sexual interest in a partner who has gained significant weight after pairing up when they both were relatively thin.  Clients who are partners of overweight men have told me, “I’m not attracted to him anymore because he’s gained so much weight, and that’s part of my ED problem, but how can I ever tell him that?”  In couples therapy, this dilemma can be explored bravely and candidly, and resolved in ways that are both honest and sensitive, by exploring all aspects of the quality of their sex life and employing sex therapy techniques to address the frustrations.  It can be productive work that gets to the heart of how to move beyond a sexual stalemate in a relationship (although other factors, such as unexpressed anger or conflict with a partner, can contribute to a sexual stalemate).

HIV

Gay men are often affected by the body shape changes due to lipodystrophy and lipoatrophy in living with HIV, putting more pressure on them than on the gay male population in general.  In therapy, the task is sometimes identifying and clarifying what can and cannot be realistically changed in the body of someone facing these challenging conditions, and whether or not change is desired or should even be attempted.  Identifying and evaluating the options for treating lipodystrophy and lipoatrophy are tasks that might  be shared by an HIV specialist physician (MD) and an expert in HIV mental health. The physician educates the patient on the medical risks and benefits, and the therapist addresses the treatment’s meaning to the patient, the cost (emotionally and financially), and realistically assessing the desired outcomes.

Team Approach

In addition to the roles of the physician and the psychotherapist, other professional providers play a role in the treatment of weight loss.  It can also be the purview of the Registered Dietitian (RD) nutritionist, and that of a Certified Personal Fitness Trainer.  Weight loss, then, can be seen as a multidisciplinary task that requires a team approach working collaboratively in service to the overweight patient, with each provider doing what he/she does best in support of the patient’s stated goals.  Other resources that a therapist might refer a patient to include Overeaters Anonymous, gay-affirmative group therapy, gyms, and gay-friendly sports organizations (which might include spinning, bicycling, jogging, circus acrobatics, volleyball, softball, skiing, triathlon training, cross-fit training, and dodgeball – all of which currently have gay men’s groups in Los Angeles).

For many gay men, however, who desire to lose weight, their conscious desire to be a healthy body weight and enjoy the social status and esthetic of the physique that goes with it, and their underlying forces that prevent achievement of that goal, may be in conflict — even unconsciously.  While the desire to lose weight can seem reasonable, in the reality of therapy, many clients are conflicted about why they want to change physically, and how.  Therapy can help the overweight patient learn how the problem began, both emotionally and physically, and can help the patient learn the relationships between stress, cortisol, “emotional eating”, family culture, guilt, entitlement, defeatist thinking, depression’s effect on body weight (over or under), and learned helplessness.  For some, being overweight can be a sign that a patient has been sexually abused in his past, and gaining weight serves as a defense mechanism (unconsciously) to “fend off” would-be perpetrators by making himself look “less attractive” (to some, not all) — even in adulthood (Morgan, 2008).

While I consider the physician to be the “team lead” among multiple professional providers who are helping the overweight patient in terms of the medical oversight needed for safe weight loss, therapy can be the “home room” of case management, where the purpose and delineated roles of the therapist, physician, nutritionist, and personal trainer can be identified, differentiated, and coordinated.  For some patients, even an aspect of financial planning is important, as electing to see many different professionals in the quest for a more healthful body weight is (curiously) not something health insurance generally covers, and people of all socio-economic statuses need help with weight management.

Some of the tasks in therapy can include exploring the history of their body image and expectations and pressures from parents (currently and in the past); cultural influences on body self-image and self-concept; identifying where and when “problem eating” occurs; and exploring the patient’s interest/aptitude/motivation for some kind of moderate exercise that will keep the patient healthy over the long term.  Exploration of the patient’s favorite types of foods, and the emotions associated with them, can be elucidating.  In addition, weighing the risks and benefits emotionally of more drastic interventions such as “lap-band” surgery can be done with the therapist, while the physician helps educate the patient on its medical risks and benefits.

Therapy with DBT and CBT

Part of Dialectical Behavior Therapy (DBT), pioneered by Marsha Linehan, Ph.D., includes the patient holding two ideas in his mind at the same time:  accepting himself as he is, but knowing he can do differently, if he wishes.  This form of therapy applies most often to Borderline Personality Disorder, and helps with affect (emotional) regulation and overall functioning, but it can be applied to weight management as well (Telch, Agras, & Linehan, 2001).  Body change and the adoption of new, permanent, enduring habits that help achieve and maintain optimal health, in part through diet and exercise, is often a combination of validation and the enhancement of the patient’s self-esteem “as he is”, but with a healthy challenge to get out of his own “comfort zone” enough to explore cognitive and behavioral change as he experiments with changing approaches to eating, exercise, socialization, and self-concept.

This coordinated, multi-disciplinary approach between physician and psychotherapist helps empower the patient to approach body change from a medically-supervised, self-empowered, self-loving, gentle approach that avoids “fad diets”, commercial weight loss devices and food products, and impulsive/irrational actions that can be risky to the patient’s physical and mental health.  By consolidating their professional points-of-view and their respective skills/efforts, the collaboration supports the patient to embrace a satisfying and healthy self-care routine that can positively impact his physical and mental health for a lifetime.

My therapeutic approach working with gay men with weight and body image issues, which over the past 20 years has resulted in consistently good treatment outcomes, uses components of DBT (particularly around validation and self-acceptance), but also explores the existential dilemmas that the overweight patient must resolve (such as, is it “worth it” to give up personal resources of time, energy, and money to attempt to “fit in” with some kind of gay cultural ideal by losing weight, or is the current state of the patient a “good enough” physiology to be reasonably healthy for the long term, while not spending resources which could be spent elsewhere, which have more worth in the patient’s personal value system).  Some people would rather eat what they want and enjoy that aspect of a quality of life, then to have “six-pack abs” and deny themselves their favorite foods in their preferred quantities and frequency; some people would rather carry extra weight (and the risks associated with it), then “bother” with exercise they find boring, repetitious, overly-strenuous, embarrassing, or inconvenient.  One cardinal tenet of clinical social work practice (that I teach my graduate students at USC) is that the patient has a “right to self-determination” in a free society.

Self-empowerment in Cognitive-Behavioral Therapy can include the serenity to accept the things they cannot (or will not) change; the courage to change the things they can; and the wisdom to know the difference.  Therapy can help a patient achieve this sense of self-empowerment, preserving his right to take control of his health.

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References:

American Psychiatric Association (2013).  Diagnostic and statistical manual of mental disorders, fifth edition.  Washington, DC:  Author.

Blashill, A.J. (2010).  Elements of male body image:  Prediction of depression, eating pathology and social sensitivity among gay men. Body Image 7(4): 310-316.  http://dx.doi.org/10.1016/j.bodyim.2010.07.006

Keel, P.K., Doer, D.J., Eddy, K.T., Franks, D., Charaton, D.L., Herzog, Dr. R. (2003).  Predictors of mortality in eating disorders.  Archives of General Psychiatry 60(2):  179-83

Morgan, J. (2008). The invisible man: A self-help guide for men with eating disorders, compulsive exercise, and bigorexia, New York, NY: Routledge.

Strother, E., Lemberg, R., Stanford, C.S., Turberville, D. (2012).  Eating disorders in men: underdiagnosed, undertreated, misunderstood.  Eating Disorders: The Journal of Treatment and Prevention 20(5): 346-355  DOI: 10.1080/10640266.2012.715512

Telch, C., Agras, W., Stewart, W.E., Linehan, M. (2001).  Dialectical behavioral therapy for binge eating disorder.  Journal of Consulting and Clinical Psychology 69(6): 1061-1065