Aspecte bioetice și comportamentale ale tulburărilor dismorfice corporale la sexul feminin și cel masculin

Introduction

Body dysmorphic disorder (BDD) is characterized by an excessive preoccupation with one or more defects or imperfections in one’s physical appearance, which the individual considers unsightly, deformed, abnormal or unattractive. These defects are not obvious to others⁽¹⁾.

Most people with BDD experience varying degrees of impairment in social, occupational and interpersonal functioning. These problems can completely destabilize an individual’s life, and can even lead to suicidal thoughts^(2,3). Many patients seek surgical intervention to correct the alleged defect. In some cases, this intervention can bring improvements, but in others it can worsen the psychiatric disorder, leaving the patient dissatisfied with the result⁽⁴⁾.

The prevalence is 2.4% among adults in the United States of America (2.5% in women and 2.2% in men). Outside the USA, the current prevalence is approximately 1.7-1.8%, with a gender distribution similar to that in the United States⁽¹⁾. In most individuals, dysmorphic disorder begins before the age of 18 years old, but the highest frequency has been recorded at the age of 12-13 years old⁽¹⁾. It can persist without treatment, presenting a chronic course.

The prevalence is slightly higher in women, especially in relation to concerns about weight and facial appearance. On the other hand, men tend to be more focused on musculature and body size, as is the case with muscle dysmorphia. The prevalence is significantly higher among university students, patients in the fields of psychiatry, dermatology and plastic surgery⁽⁵⁾.

The development of the disease is influenced by biological, psychological and sociocultural factors. These factors include media influence, childhood abuse and neglect, comments about physical appearance, stressors, first-degree relatives of patients with obsessive-compulsive disorder and patients who have undergone cosmetic surgery^(5,6).

Many people with BDD also have experienced emotional or sexual abuse in childhood. Injuries from car accidents, domestic violence or fires that have resulted in wounds, scars or skin complications can affect people’s physical appearance. Early negative experiences, such as trauma-related images, teasing, neglect or aggression, can contribute to the development of this disorder.

The degree of understanding of an individual in the context of body dysmorphic disorder, according to the ICD-11 classification, is:

a) Body dysmorphic disorder viewed from a fair to good perspective

In general, the individual can realize that their beliefs about the disorder are not necessarily correct, is receptive to an alternative explanation for their experiences.

b) Body dysmorphic disorder viewed from a weak to nonexistent perspective

Frequently or permanently, the individual strongly believes that their beliefs about the disorder are correct, and refuses to accept an alternative explanation for their experiences⁽⁷⁾.

The diagnosis of body dysmorphic disorder is extremely important, because this condition profoundly affects the mental health, social functioning and quality of life of the person and, if untreated, can lead to adverse and irreparable consequences.

The diagnostic criteria according to DSM-5-TR are:

a) Preoccupation with one or more perceived imperfections or defects in physical appearance, which are not visible or appear minor to others.

b) At some point in the evolution of the disease, the individual began to adopt repetitive behaviors (such as frequent mirror checking, excessive hair care, skin scratching or constant solicitation of the opinion of others) in response to concerns about their appearance.

c) The preoccupation causes significant discomfort in social, occupational or other essential areas of life.

d) The preoccupation with physical appearance is not better accounted for by a concern about body fat or weight in a person whose symptoms meet the criteria for an eating disorder⁽¹⁾.

The diagnostic criteria according to ICD-10 are:

a) Persistent preoccupation with an alleged disfigurement or deformity.

b) Persistent refusal to accept advice and reassurances from multiple physicians that there is nothing abnormal about the symptoms⁽⁸⁾.

Clinical features of body dysmorphic disorder indicates that BDD is a disorder of self-perception characterized by an obsession with perfection and an intense preoccupation with a nonexistent or insignificant emotional lability and short-term amnesia blackout. Stupor and coma are very dangerous stages of alcohol intoxication that can rapidly become fatal if the patient does not get proper immediate medical assistance⁽⁵⁾.

Approximately 1.8% of the global population is affected by body dysmorphic disorder, with the incidence being slightly higher in females than in males. There are similarities and differences in terms of clinical characteristics and behaviors adopted by the two genders.

In both genders, symptoms begin at a young age, around the age of 12-13, and their duration and intensity favor the emergence of comorbidities, such as depression, anxiety, stress and social anxiety. Certain regions of the body that are frequently targeted by prejudices in both genders are common, such as skin appearance. Symptoms appear earlier, and are more severe compared to those of men, which leads to a greater dissatisfaction with their appearance. They are more concerned about perceived defects in front of others. They have a significantly lower predisposition to develop muscle dysmorphia compared to male individuals.

These concerns generate irrational and time-consuming behaviors, much more repetitive, such as frequent checking of appearance in the mirror, resorting to dermato-cosmetic procedures, camouflaging the body with clothes and accessories to hide areas perceived as unsightly, changing body position and resorting to various cosmetic surgeries⁽¹³⁾. Women are more likely to develop eating disorders, adopting restrictive and hypocaloric diets, eliminating fats, drastically reducing portions and voluntarily causing themselves to vomit after eating, for fear of gaining weight, which could contribute to the development of bulimia and anorexia. Many patients turn to dermatology and reconstructive esthetic surgery offices in the hope of getting rid of these imperfections permanently. They resort to invasive procedures, such as breast implants, rhinoplasty, liposuction, abdominoplasty, blepharoplasty, facelift, etc. These interventions can be repeated even when they are not recommended by specialists, and they can have a negative impact on mental health and self-perception.

Cultural, social, genetic and life events have increased the pressure on men to improve their physical appearance, thus contributing to the emergence of male body dysmorphic disorder.

Men are more concerned with the appearance of their skin (acne or scars), thinning/rare hair (androgenic alopecia, baldness) or excess body hair, teeth, nose (shape or size), size of genitals, height and lack of muscle mass (muscle dysmorphia). They are less likely to obsess over their breasts or chest, abdomen, buttocks, hips, legs, and excessive facial and body hair than women.

Muscle dysmorphia occurs exclusively in men, and it is characterized by the belief that their body is too small or that they have insufficient muscle mass. However, they may have a normal or very well-developed muscular appearance. There is an increased risk of muscle dysmorphia among men who are gym-goers or have perfectionistic and narcissistic traits. Most people isolate themselves from social interactions, adopt an unhealthy diet, and engage in excessive exercise or weightlifting. This is linked to an increased risk of abusing anabolic steroids and other substances to increase muscle mass and reshape their bodies. Approximately 22% of men diagnosed with BDD met the criteria for muscle dysmorphia^(1,21).

The desire to look a certain way – whether through weight loss or muscle gain – makes men vulnerable to certain risks. These aspirations can also lead to dangerous side effects, such as extreme dieting, exercise addiction and conditions like depression and anxiety⁽²²⁾.

Men also resort to dermatological treatments and surgical interventions, including in the oromaxillofacial and dentoalveolar fields. Some of them choose to modify their bodies through surgical interventions, and the results can often have negative effects⁽¹⁾. They are more likely to develop substance use disorders and experience deterioration in psychosocial functioning, which can lead to unemployment or disability benefits⁽¹³⁾.

We chose the topic “comparative aspects of body dysmorphic disorders between females and males” for several reasons.

First, this is a complex topic with a strong social impact. There are significant differences between men and women in their erroneous perceptions and unrealistic expectations about their own bodies, influenced by the high standards of society. Women are more concerned with body weight and skin appearance, while men place more emphasis on insufficient muscle mass and body size. The topic offers the opportunity to analyze these differences and how social and cultural influences play a role in the development of this disorder.

The social pressures imposed by the media and social networks are different. They contribute to the decrease in self-esteem and amplify the insecurities related to the body image of each sex. Also, the promotion of cosmetic procedures and esthetic surgeries has had a negative impact on self-images, generating an unnecessary and repeated use of these procedures, individuals being always dissatisfied with the result anyway.

Body dysmorphic disorder has a very different psychological and emotional impact between the sexes. By studying this topic, we could explore how gender influences the types of anxiety or depression related to the negative perception of one’s own body in everyday life. Understanding and awareness of it can contribute to assisting those who face this disorder.

Personal experiences and those encountered in the circle of friends and family motivated us to explore the topic more deeply, because the unfavorable view of one’s own body image has been a source of suffering.

This topic may be insufficiently explored in certain contexts, which may offer opportunities for research and contribution to existing knowledge. Addressing this topic can contribute to raising awareness of body image disorders and their effects on mental health, helping to eliminate stigma and promote acceptance.

The purpose of the research was to identify similarities and differences between male and female patients suffering from body dysmorphic disorder, with the objective of better understanding how this condition manifests itself and how it influences the lives of individuals depending on their gender. The study focused on several aspects of the disorder, such as the prevalence of the diagnosis between the two genders, the areas of the body that are most frequently perceived as defective by patients, and the psychosocial and emotional impact on their daily lives. The research analyzed how BDD affects professional careers and family relationships differently depending on gender. In this context, the behaviors adopted by patients to mask or compensate for perceived defects were also be studied. Another important research objective was to identify the factors that contributed to the development of body dysmorphic disorder, considering genetic, social, cultural and psychological influences. Thus, it was explored how childhood experiences, family influences, social pressures related to beauty standards and the impact of mass media can affect men and women in different ways, leading to the development of BDD.

The working hypotheses were:

Women tend to focus more on the general appearance of the face and body, including features considered feminine, such as breasts and thighs, while men are more likely to be concerned with the development of muscle mass.

Women are more frequently affected and will present more severe symptoms of BDD than men, due to social pressures and different beauty standards for each gender.

The more negative the self-perception, the greater the severity of symptoms. If a person has a more positive perception of body image, BDD symptoms will be less severe.

Increased accessibility to online platforms, including social networks and magazines, has contributed to the formation of unrealistic expectations regarding physical appearance, which has led to an intensification of symptoms of body dysmorphic disorder, especially among young people.

Environmental factors include negative comments about a person’s physical appearance from family members or school or work colleagues, which have a strong impact on the onset of the disorder.

Methodology

The analysis of this paper is based on data collected through an anonymous questionnaire, distributed during the period 24.10.2024-05.2025, in which a sample of 370 people from Romania participated, after obtaining the approval of the Ethics Committee of the “George Emil Palade” University of Medicine and Pharmacy, Sciences and Technology, Târgu Mureș, Romania, with no. 3378 of 29.10.2024 for conducting the study. The research was conducted using a quantitative approach, aiming to obtain objective and measurable data on the behaviors, perceptions and opinions of the participants in relation to the subject studied. The sample was chosen randomly, with a balanced distribution across age groups, gender and various regions of the country, to ensure the representativeness and validity of the results obtained. The questionnaire was structured to allow a detailed analysis of the variables studied and to obtain significant statistical data, which can provide valuable information for understanding the phenomenon investigated.

Study inclusion criteria:

• female and male participants over 18 years of age, to ensure homogeneity in the study group;
• participants who have the cognitive capacity to understand the questions in the questionnaire and to answer correctly;
• participants who are available to participate in the stages of the questionnaire, including completing the questionnaire.

Study exclusion criteria:

• participants who are under 18 years of age, to comply with legal regulations on research with minors;
• participants who cannot understand the questions in the questionnaire due to communication difficulties or a language barrier will be excluded;
• participants with severe mental disorders, such as schizophrenia or personality disorders, may be excluded to avoid confounding influences on the results;
• participants who abuse substances (alcohol, drugs) that could affect their judgment or ability to participate in the study will be excluded.

In the process of developing the study, we obtained information about the patients through a questionnaire composed of 17 questions, including both closed-ended questions with simple and multiple answers, and open-ended questions, in which respondents can provide free answers, without restrictions. The types of questions included demographic questions (age, gender, background, level of education), questions about symptoms (“What is your biggest insecurity at the moment?”) and questions about behavior (“Do you engage in behaviors such as excessive grooming, wearing specific clothes or avoiding social situations to hide perceived defects?”).

The questions formulated based on the questionnaire reflect the diversity of the patients’ real experiences.

Data processing was carried out using efficient and easily accessible software tools, such as Google Forms and Microsoft Office Excel, which allowed for detailed management and analysis of the information collected. In the first phase, Google Forms was used to create and distribute the anonymous questionnaire and allowed for the automatic collection of data in a structured format, easy to process later. After completing the data collection process, they were exported to an Excel file where it was used to generate graphs and data visualizations.

Results

The participants in the study were at least 18 years old, as follows: 214 people were part of the 18-25 age group, 77 belonged to the 26-35 age group, 38 represented the 36-45 age group, 36 were part of the 46-55 age group, and in the last category, namely people over 56 years old, five people out of the total number of participants, respectively 370 people, were included.

The share of participants according to age group was, in descending order, the following: 18-25 age group – 58%; 26-35 age group – 21%; 36-45 age group – 10%; 47-55 age group – 10%; and the over 56 age group – 1%.

Of the total number of participants, 221 were female, representing 60% of the total, and 149 were male, representing 40% of the total, which shows us a predominant component of female participants in the survey.

In terms of environment of origin, of the total number of participants, 225 (69%) were from urban areas, and the remaining 115 (31%) came from rural areas.

Of the total number of persons, seven were pupils, 176 were students, 170 were employees, and 17 were pensioners.

Most female respondents, namely 158 women (71%), were aware of the term body dysmorphic disorder, followed by a percentage of 29% (63 women) who had no knowledge on this topic.

Men who knew the term “body dysmorphic disorder” constituted approximately 49% (73 men), while those who did not know the term represented 51% (76 men).

Of the total number of people surveyed, 72% (160) of women and 56% (83) of men frequently focused on certain parts of their appearance that they perceived as flawed or unattractive, while 28% (61) of women and 44% (66) of men did not focus on these imperfections. Moreover, 58% of women frequently compared their appearance to others versus 43% of men. Also, about 42% of women and 57% of men did not make such comparisons.

To the question “Do you engage in behaviors such as excessive grooming, wearing specific clothes, excessive makeup, or avoiding social situations to hide perceived flaws?”, 74 women (33%) and 35 men (23%) answered affirmatively, while 147 women (67%) and 114 men (77%) answered negatively.

Also, 35% of females (77 women) and 27% of males (40 men) stated that concerns about physical appearance had affected their work, relationships and social activities, while 65% (144 women) and 73% (109 men) denied this.

The participants were also asked if they frequently felt anxious, ashamed or depressed about their appearance: 39% of female participants (87 persons) felt emotionally affected by their physical appearance, while 61% of them (134 women) did not feel affected. Regarding men, 28% of them (42 people) felt emotionally affected by their physical appearance, and the remaining 72% (107 men) did not feel affected.

The most significant insecurities related to physical appearance of female participants are presented in Table 1, in descending ordesr.

Of the total number of female respondents, 9% did not have insecurities related to physical appearance (33 people).

The most significant insecurities related to physical appearance of male participants are presented in Table 2, in descending orderee

Of the total number of male respondents, 11% did not have insecurities related to physical appearance (27 people).

Participants were asked if they had ever considered resorting to dermato-cosmetic procedures or cosmetic surgery to correct a certain imperfection. To this question, approximately half of the women (48%; 105 people) and only 20% (30 people) of the men answered positively. The remaining 48% (116 people) of the women and 80% (119 people) of the men answered negatively.

Considering the distribution of participants according to risk factors, we can observe that 80 women (43%) believed that social pressures and unrealistic beauty standards promoted by the media have contributed to the emergence of these insecurities related to physical appearance. Also, 68 of them (36%) claimed that low self-esteem, perfectionism and obsessive-compulsive tendencies have played a role in the development of this dissatisfaction. In addition, 32 women (17%) believed that bullying, teasing or criticism related to physical appearance were causes of these vulnerabilities, and the remaining eight people (4%) believed that experiences such as abuse, intimidation or significant changes in life have had an impact on these fears. Also, 57 men (47%) claimed that low self-esteem, perfectionism and obsessive-compulsive tendencies have played a role in the development of this dissatisfaction. Moreover, 37 of them (36%) believed that social pressures and unrealistic beauty standards promoted by the media have contributed to the emergence of these insecurities related to physical appearance. In addition, 19 men (16%) believed that bullying, teasing or criticism related to physical appearance were causes of these vulnerabilities, and the remaining nine people (7%) believe that experiences such as abuse, intimidation or significant life changes have had an impact on these fears.

In the same questionnaire, participants were asked how confident they felt about their physical appearance. Of the total number of participants, 89 (40%) stated that they had good self-acceptance, although they still had some minor anxieties. A total of 79 women (36%) claimed that they felt acceptable: they managed to cope, but had moments of insecurity and doubts about their appearance. Also, 29 women (13%) stated that they felt very good and completely comfortable with who they were, loving their bodies and fully accepting themselves, and 19 participants (9%) felt less good, saying that they felt uncomfortable about certain features of their body and had difficulty accepting themselves. Finally, five people (2%) did not feel good, having a negative perception of their bodies and struggling with feelings of insecurity.

Of the total number of male participants, 66 (44%) declared that they had good self-acceptance, even if they still had some minor anxieties. A total of 35 men (24%) claimed that they felt acceptable: they managed to cope, but faced moments of insecurity and doubts about their appearance. In contrast, 33 men (22%) stated that they felt very good and completely comfortable with who they were, loving their bodies and fully accepting themselves. Eleven participants (7%) felt less good, mentioning that they felt discomfort about certain features of their body and had difficulty accepting themselves. Finally, four people (3%) did not feel good, having a negative perception of their own body and struggling with feelings of insecurity.

Regarding consulting a specialist (psychologist or psychiatrist), 30% of women (66 people) said they felt this need, while 70% (155 women) did not have this perception.

Among men, 17% (26 people) claimed they felt the need to consult a specialist, while 83% (123 people) did not feel this need.

Disscusion

Most of the people (60%) who participated in this study were female, and the rest (40%) were male. Most of the participants (58%) were aged between 18 and 25 years old, came from urban areas (69%), and were students (47%).

Regarding the knowledge of the term “body dysmorphic disorder”, there was a significantly higher percentage of women who knew it (71%), compared to men (49%). The participants had access to various sources of information, but the internet represented the largest share, with a percentage of 41% for women and 34% for men. Regardless of the age category, the people surveyed mostly had the same sources of information.

One aspect observed in the study is that 58% of women and 43% of men frequently compared their appearance with that of others. Also, 74% of women and 56% of men often focused on body features they consider flawed or unattractive. A small percentage of women and men (33% and 23%, respectively) engaged in behaviors such as excessive grooming, wearing special clothes, using excessive makeup or avoiding social situations to hide perceived flaws. Unfortunately, 35% of women and 27% of men said that concerns about their physical appearance affected their work, relationships and social activities. Feelings of anxiety, shame and depression were common in 39% of women and 28% of men.

In the questionnaire, the participants were asked to select their biggest insecurities about their physical appearance. For women, these were, in descending order: weight (25%), skin imperfections (18%), body shape (17%), teeth (11%), insufficient muscle mass (8%), hair (8%) and height (4%). For men, the main insecurities, in descending order, were: insufficient muscle mass (20%), weight (19%), body shape (16%), skin imperfections (8%), hair (7%) and height (5%). In both genders, the most common insecurities were related to weight and body shape, while hair and height are perceived as the least bothersome. Of the total number of people surveyed, 9% of women and 11% of men said they had no insecurities related to their physical appearance.

Of the 221 women surveyed, about half (48%) said they had considered having a cosmetic procedure to correct a physical defect, while only a small percentage (20%) of the 149 men surveyed had considered such an option.

In terms of classifying patients according to risk factors, the majority of women (43%) believed that social pressures and unrealistic beauty standards promoted in the media were the main risk factors. On the other hand, 47% of men said that bullying, teasing or criticism related to their physical appearance contributed to these insecurities.

Of the 370 people surveyed, 40% of women and 44% of men said they had good self-acceptance, despite some minor concerns related to their physical appearance. Only a small percentage of male participants (17%) and 30% of female participants confirmed that they had considered seeking help from a specialist.

The study confirmed the working hypotheses:

Women tend to focus more on the general appearance of their face and body, with the most frequently selected answers being related to weight, skin imperfections and body shape. Men are more likely to be concerned with developing muscle mass, this being the most frequently selected answer, followed by weight and body shape.

Women are more frequently affected, and have more severe symptoms of body dysmorphic disorder than men. They answered affirmatively in a higher percentage than men to questions related to the psychosocial and emotional impact, the behaviors adopted and the impact on interpersonal relationships. There is also a high percentage of women who would resort to procedures and surgical interventions to correct perceived defects, compared to men. The main cause of the appearance of these disorders in women is represented by social pressures and high beauty standards.

The more negative the self-perception, the greater the severity of the symptoms. Participants who selected the most insecurities also described the most varied types of surgical interventions to which they would be willing to resort.

The impact of mass media has played a significant role in shaping these unrealistic expectations related to physical appearance, promoting an idealized image of the human body, which has led to the intensification of symptoms especially among young people.

Other environmental factors that have contributed to the appearance of these disorders include bullying, teasing and criticism related to physical appearance, having a similar impact on both sexes.

Our study of body dysmorphic disorder has notable similarities to other international research, particularly in terms of social and media influences, gender differences, and psychological impact.

A 2020 study, based on searches in several databases including PubMed, Web of Science and PsycINFO, found a significant risk associated with social media use in body image dissatisfaction in people with BDD. This search identified 40 studies that met specific inclusion criteria⁽²⁶⁾.

Another 2020 study demonstrated that concerns about skin appearance were most common for both sexes. However, men reported greater preoccupation with muscle development and body structure. Women reported significantly greater distress associated with BDD behaviors. This higher intensity of distress is reflected in the psychosocial and emotional impact of BDD on their lives compared to men. The average severity of depression, anxiety, stress and social anxiety has been shown to be similar between men and women⁽²⁷⁾.

Our study, like other research, highlights the major influence of social networks and mass media on body image issues. It also confirms that women are more affected and have more severe symptoms compared to men. Like other work, the study shows that both sexes experience anxiety, depression and stress due to BDD, but women present with more intense emotional distress.

Conclusions

In this study, the results obtained after the responses of the cohort of 370 people to the questionnaire demonstrate that there are similarities and differences between the sexes in certain aspects. These differences were observed both at the level associated with body perception and in the behavioral manifestations of body dysmorphic disorder.

More women than men were familiar with the term “body dysmorphic disorder”. The sources of information were represented in both cases mainly by the internet.

A higher percentage of women than men frequently compared their appearance with that of others, paying more attention to the features they perceive as defective or unattractive and engaging in camouflage behavior. Also, a greater number of women stated that these anxieties have influenced their social life and caused them feelings of anxiety, depression and insecurity.

Regarding the main concerns related to body image, they differ between men and women, but there are also common elements, which are influenced by biological, cultural and psychosocial factors. Women frequently focused on weight, skin with imperfections and body shape, these aspects being essential in their perception of their own image. In contrast, men were more concerned with insufficient muscle mass as the main source of dissatisfaction. This is followed by weight and body shape, reflecting the pressures related to the male ideal of a muscular and well-defined physique.

Within both sexes, hair and height recorded the worst results, but these concerns also led to a decrease in self-esteem.

Of the total number of people surveyed, a higher percentage of men said that they did not have insecurities related to their physical appearance compared to women, but the percentage difference was not significant.

Women also showed a significantly higher prevalence in terms of the desire to resort to an esthetic procedure to correct a certain defect. Women had a preponderant tendency to consider rhinoplasty, while men opted more for hair implants.

An important factor that contributed to the emergence of these thoughts in women was mainly the influence of social pressures and ideal beauty standards promoted by the media. In contrast, in men, the main triggering factor was bullying and negative comments related to physical appearance.

Most respondents of both sexes stated that they had good self-acceptance, but a considerably higher percentage of women than men considered seeking help from a specialist.

Our study highlights the significant influence of social networks and the media on body image issues.

It also confirms that women are more affected and present more severe symptoms compared to men.

Our research indicates that both sexes experience anxiety, depression and stress as a consequence of body dysmorphic disorder, but women experience more intense emotional distress.

Autor corespondent:  Andreea Sălcudean E-mail: andreea.salcudean@umfst.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.