Bigorexia Is Not Recognized by Insurers — And Men and Boys Suffer for It

Men make up roughly one-third of people who struggle with eating disorders in the U.S. Some estimates show that as many as 14% will experience an eating disorder by age 40 — and they may be more likely to die from them than women. Unfortunately, appropriate medical recognition hasn’t caught up to reality, says Dr. Jason Nagata, an expert in male eating disorders. Nowhere is that gap wider, the UCSF professor told STAT News, than with muscle dysmorphia.

Also known as bigorexia, this condition overwhelmingly affects boys and men by convincing them that they are never muscular enough. Categorized under obsessive-compulsive and related disorders in the American Psychiatric Association’s Diagnostic and Statistical Manual, it frequently involves extreme dieting.

Its current classification is a problem for both patients and providers, Nagata says, since the disorder is rarely adequately recognized. He argues that muscle dysmorphia should be deemed an eating disorder in the next edition of the DSM. Situating muscle dysmorphia among obsessive-compulsive disorders makes the diagnosis mutually exclusive with eating disorders, he said, meaning that if a patient meets the threshold for one condition, they definitionally cannot be diagnosed with the other. This distinction is out of alignment with the experiences of the people Nagata treats in his clinic.

“You can’t really separate exercise and nutrition; they go hand in hand. Some people have an eating disorder…because they’re trying to become muscular, and there is no specific eating disorder diagnosis that captures muscularity concerns,” said Nagata. “It’s much more common for people to have some combination of muscularity concerns and a change in their eating in a disordered way.”

In practice, this also becomes a problem for people seeking treatment through insurance. Some patients meet every diagnostic criterion for muscle dysmorphia but one — the rule that says they can’t also have an eating disorder. So they are instead coded as having an “unspecified feeding and eating disorder,” a catchall that names nothing specific and points nowhere useful.

Coding in that way could also put providers in billing trouble, because “if you were to follow the DSM-5 definition, you should not be coding for muscle dysmorphia and an eating disorder,” Nagata said. “If they’re seeing both symptoms, some providers will code for both…but this puts them in a difficult position…[that] could theoretically get them in trouble for misdiagnosis and attract more scrutiny by insurance companies…just to get patients the treatment they need.”

Affected boys and men often carry a double stigma — the ordinary shame of an eating disorder, compounded by the fear of being outed with a condition perceived as effeminate. This can also lead to treatment delays. When patients do land in a treatment program, it’s often one where nearly everyone else is being treated for anorexia and weight loss, deepening the isolation.

Though some experts counter that muscle dysmorphia’s current placement is accurate and can be paired with an eating disorder diagnosis when needed, Nagata says that the right diagnosis is the key to everything else: better screening, more clinicians trained to spot the condition and more avenues for research to improve treatments and outcomes for all.