Secret Dietary Rituals

The Adonis Complex
by Harrison G. Pope, Jr., M.D., Katherine A. Phillips, M.D., Roberto Olivardia, Ph.D.

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Among men suffering from the Adonis Complex, secrets like Bill's are common. Not only does society forbid men to talk about their feelings of vulnerability and inadequacy, but it also indoctrinates them with the idea that only women are supposed to worry about their looks. Men, according to our society, do not — and should not — worry about their appearance or the shape of their bodies. A man who does focus on his appearance is often seen as vain, narcissistic, or "feminine." For a man like Bill, then, a Catch-22 situation arises when he begins to dwell on his body. If he doesn't talk about his feelings, the pain gets internalized and the problem persists. If he does find the courage to do so, society tells him he's being inappropriate, that he's not acting in a healthy, masculine way. Then, of course, he feels worse: more ashamed, more vulnerable, more troubled. The result of this Catch-22 situation is that most men coping with eating disorders simply keep quiet about their painful feelings. No one, therefore, can calculate exactly how many men suffer from covert eating disorders and chronic body image preoccupations like Bill's. But there's little question that today's professionals are seeing cases like his with increasing frequency. In our own clinical practice, more and more men are telling us about their concerns with eating, their bodies, and their appearance. Of course, this raises the question as to whether eating disorders are actually more common among men nowadays, or whether we are simply becoming more aware of them. We believe that both of these changes have occurred.

Many people, like Bill, still think that eating disorders are "women's diseases." But binge-eating disorder seems almost as common among men as among women, with studies in the United States typically showing a ratio of about 40 percent male to 60 percent female. That translates into a million or more men in America today with binge-eating disorder. And then, too, there are hundreds of thousands of others who actually make themselves vomit, or do other drastic things to lose weight after binges, like taking large doses of laxatives. This disorder, called "bulimia nervosa," was first recognized in women about twenty years ago, but is now increasingly being recognized in men. And we're even seeing more men with anorexia nervosa — dieting to the point of becoming emaciated — even though this condition has traditionally been assumed to affect women almost exclusively.

Furthermore, for every man who suffers from one of these eating disorders, many others have developed milder but still dysfunctional eating patterns in response to their appearance concerns. In fact, probably a third of the men in the Olympic Gym are involved in dietary rituals that affect their day-to-day lives. Jonas, a blond graduate student running on a treadmill, is constantly thinking about the fat content of his food. Sometimes he'll decline invitations to eat at restaurants for fear that he won't be able to order anything sufficiently low in fat. Last night, he went to an ice-cream shop with his girlfriend, but found to his dismay that they offered only "low-fat" rather than "nonfat" frozen yogurt. A serving of the "low-fat" yogurt contained only four grams of fat, but he wouldn't compromise, and ordered nothing at all, even though he was hungry.

Charles, a businessman in his early forties and an Olympic Gym "regular," is simultaneously listening to headphones and reading a magazine to distract himself from the tedium of his workout on a StairMaster. Dozens of times per day, he silently laments his slowly enlarging stomach and "love handles." At breakfast and lunch, he practices a rigorous dietary routine, counting every calorie that he consumes, frequently consulting his pocket "calorie counter" book. But invariably, sometime in the evening, his resolve collapses and he polishes off several hundred calories worth of M&M's and Tootsie Rolls. Tomorrow, when he wakes up, he'll resolve to be good — but inevitably, the pattern will repeat itself. The StairMaster workouts don't keep up with his candy habit; as a result, he's wondering about liposuction.

Steve, a thirtyish plumbing contractor, worries mostly about carbohydrates. He religiously uses sugar substitutes in his coffee, drinks only Diet Cokes, and never eats dessert. But most nights, when he gets home, he makes up for his carbohydrate deficit by drinking beer. After four or five beers, totaling 600 to 750 calories, he has more than erased any of the calorie savings that he achieved through carbohydrate restriction during the day. Strikingly, he worries a lot more about the look of his belly than about his level of alcohol consumption.

Armand, a lanky teenager, also suffers from food preoccupations, but he's worried that he's too thin. In an attempt to bulk up, he's constantly counting the grams of protein in everything that he eats; sometimes, in his own words, he'll "force-feed" himself to ensure that he gets at least 150 grams of protein per day. He spends more than $50 per week — a substantial portion of his income — on protein bars, protein shakes, and various other food supplements that he hopes will make him hard and muscular. It seems strange that he should worry, for in reality, Armand is already a gifted athlete, playing varsity soccer and varsity lacrosse at his high school. But he refuses to be happy with his tall, lean body. No one, not even his closest friends, and certainly not his parents, knows how much he secretly despises his appearance. In a vain attempt to quell his anxieties and overcome his own genetics, he keeps stuffing himself with protein. He's heard that excessive protein might be bad for his kidneys over the long term, but his body obsessions today override any concerns about possible damage to his body in the distant future.

The eating patterns of these men can almost all be traced to the Adonis Complex — overconcern, dissatisfaction, or outright obsessions with body image. Men who have eating disorders, especially the more severe forms, may suffer not only from a distorted image of their bodies, but also from a profoundly distorted image of themselves as men. Tragically, they often think that their preoccupations are rare or unique; they have trouble believing that other men around them in the gym could possibly be victims of similar concerns.

Some of the men with more serious eating disorders, like Bill, may also be clinically depressed. With techniques like brief psychotherapy or an antidepressant medication like Prozac, both the depression and the eating disorder — along with the associated nagging preoccupations about fatness and body image — may vanish. But since most of these men don't reveal their symptoms to anyone, they continue to suffer needlessly.

If only we could get out the message to men with eating problems that they are not alone, much of their suffering might be relieved. In the past twenty years, this approach has greatly benefited women. Since the early 1980s, news stories, magazine articles, and books have educated women about binge eating, compulsive dieting, and obesity. As a result, more and more women dared to voice their eating problems. They joined self-help groups, contacted educational organizations devoted to helping women with eating disorders, and sought therapy from knowledgeable professionals. Within less than a decade, practically every young woman in America had heard about eating disorders, knew that they were common, and knew that help was available. If a similar trend could occur for men, then men like Bill might no longer have to suffer in silence.

BIGGER BODIES THROUGH DRUGS

Elsewhere in the Olympic Gym, the Adonis Complex has bred another type of secret. In the free-weight area of the gym, Jerry, Cliff, and Vince, three high school seniors, are busy doing bench presses. All three boys are hoping to enter a local bodybuilding competition this summer, and they're feverishly working out to bulk up. They're enormously muscular, dressed in Olympic Gym sweatpants and stringy tank tops. Their tank tops are ripped, seemingly worn to shreds from long and heavy use. But actually, the rips don't quite look accidental; they're in just the right places to show off their bulging chests and shoulders.

Jerry, Cliff, and Vince are particularly distinctive because their necks and shoulders look unnaturally big in comparison to the rest of their bodies. And for good reason: they are unnatural. Over the last several years, these boys have each taken multiple "cycles" of "juice" — drugs known as anabolic steroids. Anabolic steroids are a family of drugs that includes the male hormone, testosterone, as well as numerous synthetic derivatives of testosterone. Steroids have few legitimate medical uses, and doctors won't prescribe them to athletes simply trying to gain muscle. Unless prescribed for specific medical treatment, steroids are illegal in the United States and many other countries. But these drugs are widely available on the black market through underground dealers in gyms everywhere. Taken in pill form or by injection, steroids can allow boys and men to gain huge amounts of muscle, far beyond the limits of muscularity that any ordinary man could attain without these drugs.

Vince, a good-looking boy of average height with wavy sandy-blond hair and dark brown eyes, is on a cycle of steroids right now. Every three days, he uses a needle to inject himself with almost a teaspoonful of testosterone cypionate, alternating with occasional shots of Equipoise, another anabolic steroid. Actually, Equipoise is a veterinary preparation intended only for horses — but Vince knows that it also works effectively on people, and it's cheaper on the underground market than human steroids. Vince has also managed to score some bottles of Anavar and Hemogenin pills, which he takes on top of his injectable steroids — a standard practice that steroid users call "stacking." The four steroids for this "stack" cost Vince almost all of his savings — $800 — and he's considering dealing some steroids to make a profit so he can buy more for his own use.

Amazingly, these boys' parents aren't aware that their sons are taking steroids. They think their sons' muscles are all the result of hard work, good diet, and protein supplements. Like most parents, they don't realize that it's medically almost impossible to get this big without chemical assistance. Our research indicates that there's a fairly sharp limit to the degree of muscularity that a man can attain without drugs. We believe that most boys and men who exceed this limit, and who claim that they did so without drugs, are lying.

Jerry, Cliff, and Vince can't stay this big without continuing to take steroids periodically over the years. And the longer you take steroids, the greater the danger to your body. Many scientific studies, including those from our own laboratory, have shown that steroids decrease the proportion of "good" cholesterol in the bloodstream (technically known as "HDL cholesterol") relative to the "bad" cholesterol (the "LDL cholesterol"). As a result, atherosclerosis, or "hardening of the arteries," speeds up. For every month that you take large doses of steroids, your arteries may "age" by two or three months or even more — scientists don't know for sure. But it certainly appears possible that long-term use of high-dose steroids could take ten or twenty years off your life expectancy, leading to an early death from a heart attack or clogged arteries in the brain.

Vince and his friends know these risks. Vince even witnessed the ominous change in his own cholesterol numbers when he was on steroids, because we actually measured them while he was taking a "cycle." But he tries not to think about the dangers he might face when he's older. Occasionally, he tells us, the risk crosses his mind — but the prospect of never again taking steroids, and gradually losing his muscle size, frightens him a lot more than the prospect of a stroke or heart attack decades in the future. Vince's fear of getting smaller — of no longer feeling strong, confident, and athletically successful — trumps any fears that he might be slowly killing himself.

And steroids aren't the only drugs in the bodybuilding business. Also available from local underground dealers are human growth hormone, thyroid hormones, human chorionic gonadotropin, amphetamines, gamma-hydroxybutyrate, clenbuterol, Nubain, and an array of other drugs. Some of these drugs are legally available only by prescription; others are not marketed for human consumption at all. Jerry, Cliff, and Vince know the names and uses of every one of these black market substances. They've even tried several of them along with their steroids. Each boy owns copies of underground guides on how to use these drugs to increase muscularity and lose body fat.

We know Vince well because he participated in one of our studies of anabolic steroid users. Although the study has been completed, he calls us every few months to find out if we've published any new papers on the subject, and asks us to send him copies. He reads everything he can find — all of the monthly muscle magazines, reports on bodybuilding foods and supplements, anything that contains information about bodybuilding drugs. He knows more about bodybuilding physiology and anabolic steroids than 99 percent of practicing physicians. But then, that's his business — the gym is his world.

When we first asked Vince what prompted him to take steroids, he had no trouble explaining. "I saw what it did for a couple of my friends, and I said, 'I want that for myself.' I was tired of being a small kid and being picked on at school."

"When you first started out taking steroids, did you realize that we scientists still can't estimate the long-term risks?" we asked.

"Yeah, but you can die getting hit by a truck, too," Vince rationalized. "And steroids have done more for me than any other single thing I've done in my life."

"More for you in what way?"

"In making me feel good about myself. In making me self-confident. In making me more confident with girls."

WHAT DO WOMEN REALLY THINK?

Vince's last remark brings to mind another consequence of the Adonis Complex: the strange and striking disparity between men's and women's views of the ideal male body. Recently, we developed a computerized test to look at this difference between the sexes in body perception. In this test, the computer presents an image of a male body, and then invites the user to make the image more or less muscular and more or less fat by using the mouse to click on "buttons" on the screen. The computer then poses a series of questions about body image, and asks the user to choose the body image that best answers each question. When we give the test to men, one of the questions is, "choose the male body image that you think is the most attractive to women." When we give the same test to women, we rephrase the question to read, "choose the male body image that you feel is the most attractive."

In test after test, the results of this comparison have been dramatic. The body that men think women like is typically about 15 to 20 pounds more muscular than what women actually like. We've found this discrepancy in our studies of men and women in both the United States and Europe.

If watermelon-sized muscles aren't appealing to most women, why are so many men attempting to get so big? For some men, it's simply an erroneous belief that massive muscles will improve their sex appeal. But for other men, we believe that there may be another, more surprising explanation: a new emotional problem, unique to modern society, that we call "threatened masculinity."

"Threatened masculinity" arises from the long-standing desire of boys and men to establish their "maleness" within their societal group. Throughout most cultures in history, men who exhibited traditional "male" behaviors and who succeeded at traditional "male" pursuits have received approval and respect. But nowadays, what are these male behaviors and pursuits? What can a modern boy or man do to distinguish himself as being "masculine"?

In professional settings, modern women can do almost anything that men can do. Women can fly jet fighters in combat. They can be police captains or brain surgeons or chief executive officers of multinational corporations. Women have penetrated even the most hallowed of male sanctuaries: venerable all-male military schools now accept female cadets, female journalists are allowed into the locker room to interview professional football players, and the all-male club has become nearly extinct. Of course, there's still more work to be done to give women full equality, but women's gains are impressive. As positive as these advances obviously are, however, perhaps they cause some men to wonder, in effect, "What is there left for me to do to distinguish myself as a man?"

For some men, there may be only one such thing: no matter what the triumphs of feminism, no matter what laws are passed to ensure equality between the sexes, no matter what crowning achievements women accomplish, they will never, ever, be able to bench-press 350 pounds.

In other words, muscles are one of the few areas in which men can still clearly distinguish themselves from women or feel more powerful than other men. But muscles are a tenuous foundation on which to base all of one's sense of masculinity and self-esteem.

LESSONS FROM THE LOCKER ROOM

There are at least a hundred other men in the Olympic Gym tonight, and most aren't as badly afflicted with the Adonis Complex as Scott, Bill, and Vince. But as we move back into the locker room, we continue to catch glimpses of men who, to varying degrees, are feeling embarrassed by their bodies. For example, most of the men don't take showers at the gym. They simply pack up and go home. Is it really more convenient to drive all the way home in their sweaty gym clothes than to take a shower in the locker room? How many, in reality, are simply uncomfortable with having their bodies seen in public? Looking around the locker room, we see that even some of the men who are changing their clothes do so quickly, almost furtively, as if they don't want anyone to see them. Here are big, muscular men who seem worried about exposing their bodies to other men. Curiously, the only men who seem unconcerned about taking off their clothes are forty, fifty, or sixty years old. Why are the older men seemingly more comfortable with their bodies than the younger, fitter ones?

Again, this difference between the age groups may be a symptom of important changes in our society and its attitudes toward men and masculinity. When the older men were growing up, in the times of Elvis and carhops and beatniks in the 1950s, or with the Beatles and the flower children of the 1960s, fitness and muscularity weren't a big deal. There were few media images to suggest that body appearance should be the main basis for a man's self-esteem. Steroid use was confined only to a small circle of elite bodybuilders, mostly in Southern California. Men rarely worried about their body fat. Eating disorders, such as binge eating and vomiting, were almost unheard of among males. Admittedly, the young men of the fifties and sixties had their own repertoire of hangups — but embarrassment about their appearance and muscularity wasn't typically one of them.

And so, perhaps, the older men in the locker room today may never have gotten obsessed with their bodies when they were growing up. As a result, they're not embarrassed to be seen naked by other men.

Of course, if we casually asked the younger men in the locker room, they'd probably protest that they're not really worried about their appearance at all. They'd probably provide quick explanations for why they don't need to change their clothes at the gym, or why they plan to take a shower somewhere else. But consciously or unconsciously, they may be more embarrassed about their bodies than they would like to admit. Many are unwitting victims of one aspect of an insidious masculinity code: men aren't supposed to be bothered by preoccupations with their looks. Only women are supposed to get hung up about such things. To speak of anxieties about their bodies or physical appearance, for most men, is to violate the taboo. Many men would far prefer to disavow their worries — thus internalizing their self-criticism — rather than risk the "loss of face" that would come with disclosure.

BECOMING ADONIS: THE IMPOSSIBLE IDEAL

But behind the denials, body concerns have increasingly infected millions of modern American men. For every severe or dangerous case, such as Scott, Bill, or Vince, there are dozens of less severe cases — men who cope quietly with emotional pain about some aspect of how they look. The suffering affects not only men who go to gyms like Olympic, but millions more who are too embarrassed about their appearance to be seen at a gym in the first place. In extreme cases, men may become so concerned about parts of their bodies — a balding head, a potbelly, a small penis, or some other perceived deficiency — that they do their best to avoid being seen in any public settings at all.

As clinicians and researchers in psychiatry and psychology, we've witnessed this growing male distress more and more in recent years. We've seen how the Adonis Complex can affect the lives of ordinary American men, young and old, producing a crippled masculine identity, chronic depression, compulsive behaviors, and often seriously impaired relationships with family members and loved ones.

What's particularly worrisome is that so many of these men are unaware of the societal forces that are constantly undermining their self-esteem. Boys and men have grown so accustomed to the constant barrage of supermale images in the media, and in advertising by the male body image industries, that they don't stop to question them. Rarely do they realize the extent to which they have accepted these Herculean images as sensible representations of male beauty. Instead, they change their behavior to try to make their own bodies conform to the new standard. Rarely do they consider that no previous generation in history was ever assaulted with comparable images — partly because it was impossible to create many of these modern supermale bodies before the availability of anabolic steroids. Rarely, also, do modern men fully acknowledge, even to themselves, how much their self-esteem and sense of masculinity is linked to their body image concerns. As a result of these feelings, they may become increasingly focused on deficiencies in their bodies, without really understanding why.

The starting place for healing this crisis of male body obsession — a crisis that extends across race, nationality, class, and sexual orientation — is to help men understand that they are not alone with these feelings, that millions of others share the same concerns and tribulations. It is time to help men appreciate the underlying social forces that contribute to their negative feelings about their bodies. Men must learn to acknowledge and talk about these feelings, to overcome the "feeling and talking taboo" that society has long imposed on them. And in our society, it is time to create widespread awareness about body-appearance concerns in men, and allow men to voice these concerns to those who care about and love them. We need to expose the societal and cultural forces that are inculcating new unattainable male body standards, and share the stories and voices of scores of men who have become frustrated and ashamed by their failure to meet these standards. In the pages that follow, we will describe how we, as professionals, have counseled men faced with these painful feelings. We hope to help men achieve the freedom and relief that has been attained by many women with eating disorders and other body image concerns: the ability to acknowledge their problems, seek new ways of perceiving their bodies and themselves, and find new paths toward self-confidence and fulfillment.

Copyright © 2000 by Harrison G. Pope, Jr., M.D., Katharine A. Phillips, M.D., and Roberto Olivardia, Ph.D.

About the Author

Harrison G. Pope, Jr., M.D., is a professor of psychiatry at Harvard Medical School and chief of the Biological Psychiatry Laboratory at McLean Hospital. He lives in Concord, Massachusetts.

Katherine A. Phillips, M.D., is an associate professor of psychiatry at Brown University School of Medicine, director of Butler Hospital's Body Dysmorphic Disorder and Body Image Program, and the author of The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. She lives in Providence, Rhode Island.

Roberto Olivardia, Ph.D., is a clinical research fellow at Harvard Medical School. He lives in Malden, Massachusetts.