Body dysmorphic disorder (BDD) causes people to fixate on the idea that there is something fundamentally wrong with the appearance of at least one part of their body. The condition typically emerges in childhood and affects between five and 10 million people in the U.S. BDD often leads people to spend hours every day staring into mirrors, grooming themselves, or otherwise obsessing over perceived flaws that may not actually exist, or that are so minor no one else would ever notice them. Common areas of concern include a person’s face, hair, skin, breasts, and genitalia.
Many people with BDD pick at their skin, pull their hair, bite their nails or cheeks, avoid bright light, buy tons of cosmetics, and seek plastic surgery to soothe themselves, or to attempt to change the part of their body causing them stress. But any relief that self-soothing behaviors or body modifications offer is usually short-lived; BDD distress often endures even when a person recognizes their self-perception is warped, and even if they “solve” a perceived issue, their scrutiny can shift to new body parts. The condition also often triggers or exacerbates anxiety, depression, or eating disorders. Many people with BDD come to believe others are constantly judging or mocking them. Frequently, people with untreated BDD gradually withdraw from the world.
Given the importance that most people place on looks when it comes to attraction, BDD can significantly affect people’s sex lives. Some research indicates that BDD can fuel sexual impulsivity: People may chase a brief sense of physical affirmation through sex. Conversely, others just stop having sex due to self-consciousness or isolation. Limited research suggests that, while BDD does not necessarily lead to a decrease in sex drive, it interferes with arousal, the quality of a person’s orgasms, and overall sexual satisfaction, likely because BDD causes people to get hung up on how they look and their partners’ appraisal, preventing them from engaging fully with the experience.
No one is sure what causes BDD. Although many experts believe it’s a lifelong condition, treatment with therapy and SSRIs can help people control its, including the sexual obstacles that come with the condition. Organizations like the International OCD Foundation and the BDD Foundation have started to spread awareness of the condition and treatment resources, and a handful of people with BDD are now speaking more openly and publicly about their experiences as part of these efforts. But detailed personal accounts about sex and sexuality, in particular, with BDD remain relatively rare. There are almost no accounts of LGBTQ people’s experiences with the condition.
VICE spoke to Chris Trondsen, a gay man who has lived with BDD for most of his life and a therapist who treats BDD, about his experiences with the condition within his own sex life. (Please note that this story includes a brief mention of a suicide attempt.)
VICE: When did you start to experience BDD?
Chris Trondsen: I showed signs as early as the third grade, when I started fixating on my hair. At the end of recess, I’d look at my shadow and if I thought I saw any hair sticking out of place, I’d run to a bathroom most kids didn’t use and sit there combing it. I was late to school sometimes because my hair had to be perfect; it had to be combed in a certain way, with none of it sticking up.
In eighth grade, I started to fixate on my under-eyes. I’d get ready in the morning with the bathroom lights off because I thought they made it look like I had bad rings. I also didn’t like how my stomach looked with my shirt tucked in.
Things got far worse in high school. I started thinking I had really severe acne, even though everyone told me I didn’t—and I can now look back at pictures and see that my skin was very clear. I tried to convince several dermatologists to get me on Accutane; I bullied one who was retiring into giving me a prescription, but I only used it for two months because I thought it wasn’t working. In fact, there was nothing for it to work on. When my mom stopped buying me skincare products because I was using too many and they were so expensive, I shoplifted some—and I got caught.
I also fixated on my nose in high school. I thought it was too big and I needed to get it fixed. I thought my forehead was too big, too, and that I’d need a hairline transplant to fix it. I didn’t like my jaw. I didn’t like my chin. And after I graduated, I worked at a gym, which made me think I wasn’t muscular enough.
Growing up, was there a point when you started to think about how your fixations, and the behaviors attached to them, might affect your romantic or sexual life?
My BDD didn’t feel like a disorder then. It just felt like me, so I didn’t think about it that way. And even though I always felt unattractive, I was athletic and people constantly told me I looked good. That gave me the confidence to date—although I constantly thought that I could do better than whoever I was with, or that more people would like me, if I fixed my appearance.
Actually, as a teenager who wasn’t out yet, I used dating and having sex with girls as a form of reassurance. I already knew that no part of me was interested in women at all, but I wasn't comfortable coming out because where I grew up being gay was so looked down upon, and I didn't have any friends who were gay. I just wanted to be accepted, so I forced myself into these opposite-sex relationships because I thought that if people wanted to have sex with me, it meant I must not look horrible.
But that validation never lasted, and I’d need constant reassurance from my partners—like telling me that I looked good and they were really into me, not just pretending. I demanded so much from the people I was with. And if they didn’t want sex, I couldn’t accept that it was because they were tired or something like that. It had to be because I was, say, gaining weight and they weren’t attracted to me anymore.
What was your mindset like during sex?
During sex, I was always freaking out, thinking things like, I wish we had better lighting. I’m having a bad skin day. We’re making out and they can really see all my acne and redness. I wish I could keep my shirt on. I don’t like this position. It makes my stomach look big. The fact that someone wanted to have sex with me, and the compliments I got after sex, were what gave me reassurance. But I’d only feel good for a day or two after having sex before I’d need more validation. So, if I was in a relationship, I’d make sex into a big focus. If I was single, I’d constantly need new partners. Either way, it was like I’d suck a person dry of all the reassurance they could give me, and then I’d need to move on to the next person immediately.
You mentioned not liking certain positions and kinds of lighting. Did you develop habits to try to control your appearance during sex?
Definitely. I had rituals like keeping the lights off and a tank top on, lying a certain way on the bed, not switching into any position that I thought made me look bad, and even making sure the room I’d have sex in was cold so that I wouldn’t sweat as much—because I thought sweat made me look really oily and red.
Outside of long-term relationships, I was never comfortable laying all of those rules out to a partner, so they were mostly secret rituals. I’d only invite people over to my house so that I’d be able to control the environment entirely. I’d set up almost my entire bedroom to make me feel better about my appearance, both during and outside of sex.
How did those rituals affect your ability to engage with sex in the moment?
I don’t think I ever really enjoyed sex until after I got treatment for my BDD, which coincided with my coming out in my 20s. Sleeping with women earlier in my life had always felt hollow—like something I was doing because it’s what I was supposed to do. Sex in general felt like a necessary evil, something I had to do to feel good, and that I had to do in a way that hid enough of me so that this person wouldn’t see that I looked bad. I mean, obviously there was some ejaculatory pleasure, but I don’t think I enjoyed that as much as other people, because I was constantly in my head about everything going on during sex and how I looked because of it.
When did you get diagnosed with BDD and start getting treatment for it?
It’s not a happy story. In college, my BDD got really severe. I thought I was so disgusting that any kind of intimacy was difficult, because I was sure no one would ever want to be near me. I slowly switched over to avoiding dating until I just stopped having sex for years.
My BDD fueled a lot of depression as well as isolation. When I was around 21, I attempted suicide. Luckily, my roommate found me, and my family helped me to find mental health help. When I opened up to a therapist about my issues with my appearance, and all my rituals around that, they sent me to specialized treatment for obsessive-compulsive disorder (OCD). That therapist said that, while it seemed like I did have OCD, it also seemed like something else was going on. She sent me to a support group started by a therapist who specialized in BDD to get evaluated by their specialist facilitator. When he read off the list of criteria for the condition, burst into tears, because it was the first time I’d ever heard somebody articulate how I always felt.
I was in that group for two years, then in one-on-one therapy for another two years, before I was able to recognize that a lot of my thoughts about myself were overblown, and that I was the only one seeing them. I also got on medication to help with my symptoms. BDD still affects me, but not to the point that I can’t function—or can’t have a sex life—in the way it did in my early adulthood.
How did treatment help you deprogram your rituals around sex and dating, specifically?
Part of the treatment was pushing myself to go on dates and be intimate with people. But it was less about reprogramming, more about relearning how to date, be intimate, and have sex entirely.
Part of that need to learn all this from scratch was due to the fact that I didn’t come out until I was an adult. When I wasn't dating or having sex, I didn't see any point in coming out, then doing nothing about it. By the time I’d stopped having sex, I’d fooled around with a couple of guys, but it was always late at night, in the dark, and sporadic because I was keeping that hidden. I’d never had a real relationship with a man.
I found that gay male dating culture is much more image-conscious than I was used to. I’d see guys at nightclubs arguing over a third guy, saying things to each other like, “You’re fat and your nose is big!” I thought, Oh no. If somebody says that to me, I’m going to crumble. Also, now that I was regularly with men, I found myself comparing my body to my partners’—looking at their abs, skin, or penis, then feeling inferior to them.
How did treatment help you avoid getting triggered by all that, and potentially spiraling?
In the treatment I underwent, I was actually told that I would get triggered, and that I would have a choice: With sex and dating, I could go back to not engaging with people and feeling safe. But if I did, I would never form any intimate connections with people. So, the focus was on helping me learn how to manage my response to triggers—although, over time, some of my triggers did fade.
For example, when I’m having sex with a guy, rather than allowing myself to scan his body and make comparisons, feeding my sense of inferiority, I keep my eyes on his eyes, and focus on his experience. It’s almost like a mindfulness practice. It wasn’t an overnight solution. I had to have a lot of sex to learn to keep my focus, and eventually to start letting go of my need to compare myself to a partner—and of my compulsive rituals around sex that actually made me feel worse.
Did you end up developing a new list of sexual no-gos, like focusing on a partner’s body parts, or a new list of must-do practices, to help you maintain focus and avoid pitfalls?
No, because if I tried to set the parameters for sex, I’d just move back towards things that made me feel comfortable but that fed into my BDD. Like, I would never have sex in missionary, because then we'd be looking right at each other and my perceived flaws would be on full display. I preferred positions where my partner couldn't see my stomach, like doggy style.
During treatment, I also hadn’t separated myself from my disorder fully enough to know what I actually liked sexually—what worked for me in sex. So, I usually let my partners lead the flow of sex instead and just kept my focus. And when things came up, like my partner touching my stomach, that triggered my feelings of inferiority, I’d say to myself, No, you’re not going to give in to BDD, you’re going to stay in this.
You’d think that giving up control over sex might make me feel worse. But I found that when I wasn’t focused on any list of must-dos or no-gos, I actually had fewer distractions, which made it easier to lose myself in the pleasurable elements. That helped me start trusting my therapist’s advice that if I dropped my compulsive behaviors I’d start feeling better. Doing things I feared—like trying new positions, having sex in places like hotels that I couldn’t control, and keeping the lights on—felt bad in the moment, but made me feel freer in the long term. I felt like I had control over my life again, instead of my BDD taking control over me.
How did you motivate yourself to push through discomfort in those situations, though?
I really wanted love and a relationship. So, loneliness motivated me. I wasn’t going to find the intimacy I wanted unless I pushed through my BDD discomfort. The desire to find that connection and enjoyment was greater than my fear.
Being in therapy and a support group helped, as well. When I was having a bad day or a bad week, focusing on my perceived inferiority, I’d always have people who understood what I was going through supporting me, helping me to keep pushing forward.
What kind of work do you do regularly now to maintain your current mindset?
What’s hard about BDD is that our bodies never stop changing as we age, and society does not champion those changes. We don’t say that 50-year-olds look as good as 20-year-olds. So, it’s hard to not to start feeling newfound concerns about my appearance. I just have to constantly remind myself that I’m a harsher critic of my appearance than anyone else, and that a lot of the things I see in myself are things that other people don’t actually see in me. I also remind myself that even if I’m not fully happy with my body right now, it doesn’t mean that I’m not worthy of sex and intimacy and have to cut myself off from those things until I look a certain way.
I remind myself that if I focus on making my BDD happy, I’ll become a shut-in and never have intimacy with anyone. And when I’ve made my disorder feel better in the past, I as a person have felt absolutely terrible. And I know that there is hope. If you seek treatment and put in the hard work to follow it, you can have a fully satisfying sex life. You can be happy.
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