Men & Mirrors: A Budding Obsession
By Jennifer Thomas
HealthScout Reporter
SUNDAY, April 15 (HealthScout) -- On a busy Friday night in a Southern California gym, two dozen men sweat and groan as they lift weights in front of four mirrored walls, staring at their muscles for signs of growth.

"You're never satisfied with the way you look," says Roger Stewart, who's working on his pectorals in a T-shirt that proclaims, "Look Better Naked."

"You always want to improve," he adds. "A lot of guys want to look like Arnold Schwarzenegger. They like his physique and wish they could have it."

Think worrying about your appearance is a "woman's thing?" Not anymore, mental health professionals say. Increasingly, some men are as preoccupied with their looks as some women.

Psychologists say the quest for abs like the Soloflex man and shoulders like rapper-turned-actor Mark Wahlberg -- plus a full head of hair and flawless, tanned skin -- is creating problems in men typically associated with women: eating disorders and body obsessions.

"We live in a society that is very appearance-oriented," says Roberto Olivardia, a clinical psychologist at McLean Hospital in Belmont, Mass., and co-author of The Adonis Complex: The Secret Crisis of Male Body Obsession. "The message is: 'If you look perfect, you are perfect.' A lot of men feel inadequate and are very depressed because they feel they don't measure up."

For some men, anxiety over their appearance manifests itself in eating disorders such as anorexia and bulimia. Men account for about 10 percent of the estimated 7 million to 10 million Americans with eating disorders, says Mark Klug, national outreach representative for Rogers Memorial Hospital in Oconomowoc, Wis., which runs a male-only eating disorder treatment facility.

Other men develop body dysmorphic disorder, a pathological preoccupation with a particular body part they believe is flawed. In men, a common form of this disorder is what's being called "bigorexia," an obsession with being muscular and a fear of being too small, says Dr. Eric Hollander, a professor of psychiatry at Mt. Sinai School of Medicine in New York City.

About 1 percent to 2 percent of American men have body dysmorphic disorder, Hollander estimates. Of those, about 25 percent have bigorexia, he says.

Men with bigorexia are prone to depression, using anabolic steroids and forgoing social events to spend several hours a day at the gym, lifting weights. Some continue to exercise even after they've suffered a serious injury, such as a dislocated shoulder, Hollander says.

The media's powerful pull

What's driving men to become obsessed with their physiques? Doctors say a variety of causes contribute, from brain chemistry to the media.

Hollander believes bigorexia is a type of obsessive compulsive disorder, which drives people to repeat an action or a behavior over and over. Men with bigorexia often look at themselves in the mirror frequently, eat a strange or restrictive diet and exercise until exhaustion.

But the media also play a role, he says. In men's magazines, advertisers prey on the insecurities of many men, using modern-day Adonises with washboard abs, broad shoulders, slim waists and white teeth to peddle diet aids, fitness machines, baldness remedies, vitamins and an array of other products.

"You need to have a genetic or biological predisposition to the disorder, but constant bombardment with unrealistic images can contribute," Hollander says.

Indeed, in the American media, men's looks count more than ever, Olivardia says.

"Advertising is using the male body as a commodity, just like the female body has been used as a commodity," he says. "Nowadays, young boys are being bombarded with images they weren't seeing 20 years ago."

That's a far cry from past ideals of male perfection. Not so long ago, bodies of the manliest men in popular culture looked a bit more ordinary. Think John Wayne in the '40s or Steve McQueen in the '60s.

But in the last several decades, images of the ideal male body have grown increasingly more muscular. In one recent study, Olivardia and his colleagues compared the muscularity of action figure toys, past and present.

Scaled to human dimensions, the original 1965 G.I. Joe would have a biceps circumference of about 11* inches -- similar to an ordinary man, they found. However, the 1995 G.I. Joe Extreme would have 26-inch biceps -- larger than any bodybuilder in history.

Another factor fueling men's obsessions is an emphasis on youth, Olivardia says. And he believes that's one reason increasing numbers of men are getting plastic surgery.

Last year, 107,00 men in the United States had cosmetic surgery -- almost double the number in 1992, when 54,845 men had cosmetic surgery, according to the American Society of Plastic Surgeons. Men now account for 11 percent of the total. "Being young is very, very important, especially in today's dot.com business world," Olivardia says. "Men believe in order to stay competitive you have to look good, and that means looking young."

Lining up for liposuction

The most popular procedure among men? Liposuction. That's when a surgeon suctions out fat using a hollow tube called a cannula to slim down a so-called "problem area," such as love handles or the abdomen.

Last year, nearly 33,000 men had liposuction, about a 33 percent increase from the previous year, according to the plastic surgeons' group. Some men even are requesting abdominal "etching," which involves having the surgeon remove fat in a way that results in a "six-pack" stomach.

Liposuction is followed by eyelid surgery, nose jobs, breast reduction and facelifts on the most-popular procedures list. And some men are requesting chest and calf implants these days.

The top two reasons men cite for getting plastic surgery: to improve self-image and enhance a career, according to a survey by the Chicago-based American Academy of Cosmetic Surgery.

Back in the Southern California gym, Burt Brigada, 42, says he feels it's unfair to label men who lift weights as candidates for mental disorders. Brigada says his motivation for working out five days a week is just to stay fit, although he admits "vanity" and "insecurity" play a role.

"You're never totally happy," Brigada says as he sweats off a week of sitting behind a desk. "If you have 20-inch arms, you'd be looking for 21-inch arms."

But for all the men who develop full-blown body dysmorphic disorders, countless others cope quietly with insecurities about their physiques, Olivardia says.

"Regular" guys should take heart, however. While men think women dig big, bulging muscles, in fact women seem to prefer more ordinary-looking guys.

A survey of 200 college-age men in the United States, Austria and France found that men want -- and believe women desire -- a body with at least 27 more pounds of muscle than they actually have, according to research published in a recent issue of the American Journal of Psychiatry.

But Austrian females surveryed said they preferred a more typical, less-muscular male physique. While women in the United States and France were not surveyed, previous research has found they have similar tastes.

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Computer imaging in cosmetic surgery:
Pros outweigh cons

By manipulating people's facial features on computer images, doctors can help patients envision the results of cosmetic surgery. But what if the surgical results differ from those on the screen? Does computer imaging tend to raise false hopes and invite malpractice suits? Used conservatively and wisely, computer imaging actually protects both doctors and patients, concluded facial plastic surgeon Dr. R. James Koch in a newly released report examining the legal and professional implications of computer imaging in plastic surgery.

"There is potential for it to be a great tool or a dangerous tool," noted Koch, an assistant professor of surgery. "The best use of computer imaging is for improving communication -- not for selling an operation." Koch instigated a careful review of the practice by approaching Andrea E. Chavez of Stanford Law School with his concerns. "I thought it was important for lawyers to look at the pluses and minuses and come to a conclusion about the risks," he said.

Koch and Chavez reported their findings in the November issue of the journal Plastic and Reconstructive Surgery. The benefits of computer imaging greatly outweigh the risks, they found. Cosmetic surgeons can use the images to convey a sense of technically achievable results so that patients' expectations will align with reality. And those same images can later help surgeons prove that they didn't exaggerate.

Plastic surgeons who don't use computer imaging might choose instead to draw on a patient's photograph or make a diagram of the predicted surgical results. Many others forgo visual representations altogether and simply describe the changes in words.

Computer imaging allows plastic surgeons to show patients a range of possible outcomes. The software alters the images, but the doctor has to tell it what to do. Creating plausible pictures therefore requires expert knowledge of facial structure and the limitations of possible operations, Koch said.

"If you have a real small chin and I pull it out [on an image] to show you what you would look like with a bigger one, I have to know that I have the right implant to use -- one that won't distort the skin next to your chin," he explained. "The surgeon using the program has to know if the operation will work technically."

With today's software programs, cosmetic surgeons can choose to "wipe away all the wrinkles on a person's face, or to wipe away only 50 percent of them," Koch said. "I recommend that surgeons show a reasonable -- not a perfect -- result."

Demonstrating diverse outcomes and keeping predictions conservative can protect surgeons as well as patients, making it harder for patients to claim that surgeons induced them to undergo surgery with deceptively optimistic computer imaging.

In fact, responsible use of computer imaging can help patients figure out when they don't want surgery. Koch described one patient who had a hump on her nose that had been bothering her for 20 years. When he altered a computer image to show her what he thought he could do, she urged him to go farther. Koch explained that taking more tissue would distort other parts of her nose. "Maybe you should reconsider whether you want the operation," he told her.

Computer imaging also helps surgeons prepare for difficult cases and facilitates medical education, said Koch. "It's good for surgical planning. I can simulate the results of operations and move things around. It's also great for teaching residents -- much quicker than doing operations on people and waiting for them to heal," he said.

"Patients should understand that the technology is there and that when a surgeon uses it appropriately, it can be very helpful in terms of seeing what the possible outcome is before taking the step of surgery," Koch said.

"People shouldn't just get a surgeon who's got computer imaging, though, because it could be someone trying to sell operations," he added.

The vast majority of doctors doing cosmetic surgery use the imaging technique appropriately, Koch said. But warning bells should go off if a doctor shows a patient a picture-perfect result. "If the result seems unbelievable, the patient should ask the surgeon if it's technically achievable," he said.

A doctor's aggressive attempt to peddle an operation should serve as another signal to proceed with caution. It's reasonable to show a person the predicted outcome of a particular surgical procedure, but sales pitches don't belong in the doctor-patient interaction, said Koch. "The patient should make the decision. The doctor should not say, 'This is what you need.'

"The best protection for everyone is happy patients," he added. "That's what we all want."

Copyright © 1997 Stanford University Medical Center News Bureau.

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Plastic Surgeons Welcome Coverage For Breast Reconstruction in Omnibus Budget Bill

ARLINGTON HEIGHTS, IL (October 22, 1998) -- The American Society of Plastic and Reconstructive Surgeons (ASPRS) applauds the provision signed yesterday by President Clinton and passed by the House and Senate this week, requiring insurance companies to cover the cost of reconstructive breast surgery for women who have undergone a mastectomy. This measure, added to the omnibus spending bill by Senator Alfonse D'Amato (R-NY), also clarifies that coverage includes procedures to restore and achieve symmetry on the opposite breast.

"This provision, which ASPRS and Senator D'Amato have championed for two years, will enable women who have faced this terrible disease to complete the healing process without having to fight another battle, this time against their insurance company," said ASPRS President Paul Schnur, M.D.

ASPRS has been working with Senator D'Amato, other medical specialty groups, breast cancer survivor groups and women's health groups to push for legislation to require insurance companies to cover these procedures. A recent survey of ASPRS member physicians found that 84% of those surveyed reported having patients who were denied coverage for breast reconstruction following mastectomy. This provision will now allow women who choose reconstructive surgery to have the procedure covered by their health insurance plan.

"We wish to thank Senator D'Amato for fighting to ensure complete treatment for victims of breast cancer," said Jack Bruner, MD, chair of the ASPRS Government Relations Committee. "This federal legislation, enacted this month during breast cancer awareness month, will now provide protection for those women whose insurance plans fall outside the scope of the many state laws passed to guarantee coverage for these procedures."

Christine Horner-Taylor, MD, an ASPRS member from Kentucky, was an early advocate of breast reconstruction legislation. "This day is a dream come true! We have worked very hard over the past three years passing legislation in the states and working federally to guarantee women the human dignity to be made whole again without insurance battles," said Horner-Taylor. In recent years, 29 states have passed laws requiring insurance coverage for breast reconstruction. The new federal statute will not preempt state laws providing at least the same level of coverage.

ASPRS also expresses its appreciation to the other original sponsors of breast reconstruction bills in this Congress, Sen. Diane Feinstein (D-CA), Sen. Edward Kennedy (D-MA), Rep. Sue Kelly (R-NY) and Rep. Anna Eshoo (D-CA), as well as all 43 co-sponsors in the Senate and 306 co-sponsors in the House.

ASPRS represents 97 percent of all physicians certified by the American Board of Plastic Surgery (ABPS). By choosing an ASPRS member plastic surgeon who is certified by ABPS, patients are ensured that the physician has graduated from an accredited medical school and completed at least five years of additional residency, usually three years of general surgery and two years of plastic surgery. To be certified by ABPS, a physician must also practice plastic surgery for two years and pass comprehensive written and oral examinations. Consumers may call the Plastic Surgery Information Service at 1-800-635-0635 or access the ASPRS web site at www.plasticsurgery.org.

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