Exploring Muscle Dysmorphia Among Trans and Non-Binary People

Trans and non-binary people often face intense pressure around muscularity in gym culture and fitness spaces. Unfortunately, Chicago is no exception.  A growing but less-recognized issue in these environments is muscle dysphoria—a distinct form of body image distress that disproportionately affects gender-diverse people.

Muscle dysmorphia, sometimes referred to as muscle body dysmorphia, is a condition where a person becomes preoccupied with the belief that their muscles are too small or inadequate, despite often being highly developed.

This disorder is a subtype of body dysmorphic disorder (BDD) and is distinct from gender dysphoria. However, for trans and non-binary people, these conditions can overlap in complex ways, often influencing self-perception and mental health.

To better understand the intersections of muscle dysmorphia, gender identity, and LGBTQ+ mental health, we spoke with a Chicago-based LGBT therapist, Dr. Tyler Fortman, specializing in working with trans and non-binary clients. Below is an excerpt from our conversation.

Conversation with an LGBTQ Therapist

We asked: Thank you for speaking with us today. Let’s start with the basics—what exactly is muscle dysmorphia?

LGBT Therapist: Thanks for having me. Muscle dysmorphia, or muscle body dysmorphia, is a psychological condition where someone becomes obsessed with the idea that their body isn’t muscular enough.

This is often despite being in excellent physical shape or even having an objectively muscular build. It’s a form of body dysmorphic disorder (BDD), which means the distress is deeply internal and not necessarily based on reality.

People with muscle dysmorphia often engage in excessive exercise, strict dieting, and even substance use—such as steroids—to achieve their idealized muscular physique. They might spend hours in the gym, restrict their food intake in unhealthy ways, and feel really distressed if they miss a workout or perceive their body as less muscular than they want it to be.

We asked: That sounds intense. How does muscle dysmorphia compare to body dysmorphia and gender dysphoria? Are they related?

LGBT Therapist: Great question. Body dysmorphic disorder (BDD) is a broad mental health condition where someone becomes fixated on perceived flaws in their appearance. Muscle dysmorphia is a specific subtype of BDD that focuses on muscularity.

Gender dysphoria, on the other hand, is about the distress that arises when someone’s gender identity doesn’t align with the sex assigned at birth. While gender dysphoria is not a body image disorder in the same way BDD is, the two can overlap.

For example, a transmasculine person might feel compelled to build muscle as part of their gender expression, but if that drive becomes obsessive and distressing, it could indicate muscle dysmorphia rather than just a gender-affirming behavior.

We asked: What are some signs and symptoms of muscle dysmorphia that people should look out for?

LGBT Therapist: Some common ones are:

• Spending excessive time in the gym, often to the point of neglecting other responsibilities or relationships.
• Feeling really stressed out and anxious if a workout is missed.
• Extreme fixation with diet and protein intake.
• Use of anabolic steroids or other performance-enhancing substances.
• Constant checking of one’s body in the mirror or avoiding mirrors altogether due to dissatisfaction.
• Social withdrawal due to anxiety about body image.
• Feeling that one’s muscles are never “big enough,” despite evidence to the contrary.

We asked: Is muscle dysmorphia more common in LGBTQ+ people, particularly trans and non-binary people?  If so, why?

LGBT Therapist: Yes, absolutely. Research shows that muscle dysmorphia is more prevalent among LGBTQ+ people, especially trans and gender-diverse people (Nagata et al., 2021; Amodeo et al., 2020), as well as gay men. The reasons for this are multifaceted.

Many transmasculine people experience pressure to build muscle as a way to affirm their gender. For transfeminine people, muscle dysmorphia can manifest in the opposite way, where they become distressed over having too much muscle.

Additionally, non-binary people who don’t conform to traditional gender norms often struggle with body expectations that don’t fit neatly into binary categories.

We asked: What kind of treatment options are available for muscle dysmorphia?

LGBT Therapist: Treatment for muscle body dysmorphia often involves cognitive-behavioral therapy (CBT), which helps clients identify and challenge distorted thoughts about their bodies, or a depth approach that explores the underlying causes (such as internal family systems (IFS therapy) or psychodynamic therapy).

Exposure therapy—such as gradually reducing excessive workouts—can also be effective. Medications like SSRIs may help in severe cases where obsessive thoughts are overwhelming.

What’s critical, though, is working with an LGBT therapist who understands gender identity and can provide affirming care. Standard treatment models don’t always address the nuances of muscle dysmorphia within the context of gender dysphoria, so a therapist who specializes in LGBTQ+ mental health is key.

We asked: Why is it so important for trans and non-binary people to see an LGBT therapist for muscle dysmorphia?

LGBT Therapist: Because mainstream therapy approaches often don’t consider gender identity when treating body image issues. An LGBT therapist can help clients distinguish between distress stemming from muscle dysmorphia and that related to gender dysphoria, and they can provide gender-affirming strategies for self-acceptance.

They are also more attuned to the relationship between gender expansiveness and trauma and how those experiences can cultivate body dysmorphia.

A non-affirming therapist might assume the solution is to “let go” of body modification goals entirely, whereas an LGBT therapist understands that some body-related changes can be empowering and gender-affirming when approached in a healthy way.

We asked: What other mental health conditions often co-occur with muscle dysmorphia?

LGBT Therapist: Many people with muscle dysmorphia also struggle with eating disorders, depression, anxiety, trauma, obsessive-compulsive disorder, and substance use disorders.

We asked: Any final thoughts for trans and gender expansive readers who may be struggling with muscle dysmorphia?

LGBT Therapist: If you’re feeling trapped in concerns about your body’s shape, know that you’re not alone. The right support can make all the difference. At our practice, Tandem Psychology, I’ve seen so many queer people build healthier, more affirming relationships with their bodies.

Whether you’re looking for guidance, validation, or just someone to listen, individual therapy can provide the space to explore what feels right for you. Healing is possible, and your body—muscular or not—is already enough. And hey, we even promise not to make you talk about protein shakes unless you want to!

Muscle dysmorphia is a serious but under-discussed issue within the trans and non-binary community, particularly in cities like Chicago, where fitness culture and LGBTQ+ identities intersect. By recognizing the signs and seeking affirming care, individuals struggling with muscle dysmorphia can find relief and move toward a healthier relationship with their bodies.

If you or someone you know is experiencing distress related to muscle body dysmorphia, consider reaching out to an LGBT therapist who specializes in gender-affirming care.

This blog is made for informational and educational purposes only. It is not medical advice. The information in this blog is not intended to (1) replace a one-on-one relationship with a qualified licensed health care provider, (2) create or establish a provider-patient relationship, or (3) create a duty for us to follow up with you.