Abstract
Purpose
Little is known about Asian cisgender men’s body image dissatisfaction (BID) and its variation among heterosexual, homosexual, and bisexual men. This study aimed to explore and better understand their specific BID concerns regarding various body parts and desired changes in physical attributes (DCPA), shedding light on the intersection of BID and sexual orientation among Asian men.
Materials and Methods
A cross-sectional anonymous survey was conducted among participants recruited through the popular online forum, PTT, which attracts a large youth population in Taiwan. The inclusion criteria were: cisgender men; aged 18 years or older; Taiwanese citizens. The prevalence and levels of BID for nine specific body parts and prevalence of DCPA were compared by sexual orientation. Pairwise mean differences and multivariable logistic regression models, adjusting for age and body mass index, were estimated for subgroup comparisons.
Results
Of 632 participants, 376 self-identified as heterosexual, 185 as homosexual, and 71 as bisexual. The overall BID score and four body-part BID scores (i.e., facial features, skin, muscles, and penis) significantly differed by sexual orientation, with homosexual and bisexual men exhibiting higher BID than heterosexual men. Further DCPA analysis found significant sexual orientation differences regarding 27 DCPA items. Homosexual men most often reported desiring to change 18 of these DCPA, whereas bisexual men most often endorsed the remaining nine DCPA (e.g., an upward curve of the penis, a larger glans).
Conclusions
These findings reveal sexual orientation disparities in BID and DCPA, providing valuable insights for addressing body image concerns among Asian men.
Keywords: Body dissatisfaction, Body image, Desired changes in physical attributes, Men, Sexual and gender minorities, Taiwan
INTRODUCTION
1. Body image dissatisfaction and mental health vulnerabilities among sexual minority men
Body image dissatisfaction (BID) is a global issue that deeply impacts mental health and well-being. However, previous research on BID has predominantly focused on women [1], leading to a critical gap in understanding men’s experiences, particularly among sexual minority men, who face unique challenges. BID has been linked to increased risks of suicide and disordered eating behaviors, with homosexual and bisexual men showing higher vulnerability [2,3]. This concern has been amplified by a rising trend of disordered eating behaviors among young men more broadly [4]. In Taiwan, recent studies reinforce this concern, highlighting that the overall suicide rate is notably higher than the global average [5]. Compounding this, attempted suicide rates have reached up to 24.4% among lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) adults, particularly young men and students [6].
Moreover, BID has been associated with dysmorphia, a condition characterized by dissatisfaction with physical appearance and distorted body image [7]. Prior research has found intrusive thoughts regarding BID linked to greater muscle dysmorphia symptoms and comorbid suicidality [8]. Conformity to masculine norms has also been associated with increased muscle dysmorphia symptoms [9], particularly among South Asian and Middle Eastern men [10]. Furthermore, these symptoms have been observed alongside maladaptive coping behaviors, such as drug use among young men [11]. Collectively, these findings underscore the importance of addressing BID among sexual minority men, given its potential relevance to a range of mental health vulnerabilities.
2. Scarcity of BID research among Asian sexual minority men
BID research is particularly scarce among Asian sexual minority men. Cultural factors, including emphasis on physical appearance and heightened body criticism in Asian societies [12], influence BID. While research has highlighted body image issues among Asian women, including a strong drive for thinness [13], little is known about body image perceptions among Asian men, particularly in Taiwan. Although an earlier study suggests that Taiwanese heterosexual men are less preoccupied with body image than their Western counterparts, this may not hold for sexual minority men, who face distinct pressures [14]. This gap in BID research among Asian men highlights the need to examine these experiences in non-Western contexts.
3. Limited focus of previous BID research among men
Similar to women’s BID research, research among men initially focused on weight and body fat, before shifting to muscularity, a trait deemed appealing by women [15]. However, recent research, including Tiggemann’s seminal study among white heterosexual men, identified other physical features, such as height, hair, and penis size, as important contributors to men’s BID [16]. These overlooked aspects call for a broader investigation into BID that includes a wider range of physical attributes, especially among sexual minority men.
4. Unique experiences of bisexual men lacking in BID research
Although homosexual and bisexual men both struggle with BID, bisexual men face additional psychological stressors related to biphobia, monosexism, and heteronormativity [17]. Research shows that bisexual college students are more prone to mental health issues, self-harm, suicidal thoughts, and attempts [18]. However, bisexual men are often grouped with homosexual men in research, obscuring their unique experiences. Given the link between BID and mental health risks, it is crucial to understand bisexual men’s distinct experiences.
5. The current study
This study addressed the existing knowledge gap in BID research among Asian men by examining BID among heterosexual, homosexual, and bisexual subgroups in Taiwan. By adopting an exploratory approach, this study aimed to: (1) investigate the prevalence and levels of BID concerning specific body parts; (2) explore desired changes in physical attributes (DCPA) across various body parts; and (3) compare these results by sexual orientation. Taiwan’s progressive stance on LGBTQ rights, including being the first nation in Asia to legalize same-sex marriage, makes it an ideal setting for this research. This study’s findings could provide novel insights into the sources of BID among Taiwanese men, particularly within the underexplored bisexual subgroup, and inform interventions tailored for different sexual orientation subgroups, with implications for similar populations in other Asian countries.
MATERIALS AND METHODS
1. Participants
A cross-sectional anonymous survey was conducted among participants recruited through PTT, a popular online forum among Taiwanese youth. An advertisement describing the study, along with a link to the online questionnaire, was posted on PTT. Participants were incentivized by a lottery of 20 winners chosen at random, each receiving 500 P coins (PTT’s virtual currency for interactions and board activities inside PTT). The inclusion criteria were: (1) cisgender men; (2) aged 18 years or older; and (3) Taiwanese citizens.
2. Ethics statement and procedures
All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study protocol was reviewed and approved by the institutional review committee of the National Taiwan University College of Public Health. Informed consent was obtained from all individual participants included in the study.
The inclusion criteria and informed consent information were presented on the survey’s cover page to obtain informed consent before participation. It stated that voluntary completion of the survey constitutes consent to participate and that those who do not consent to participate could close their browser at any time to withdraw from the study.
To ensure respondents were humans, not bots, we conducted a duplicate-IP check and found no duplicate IP addresses in our dataset. We also performed a completion-time filter by manually reviewing submission timestamps; all responses exceeded our established minimum completion time of five minutes.
3. Measures
1) Sexual orientation
Sexual orientation among these cisgender men was assessed with the question: “By which gender are you sexually aroused?” Participants who answered “men” were classified as homosexual, those who answered “women” as heterosexual, and those who answered “both” as bisexual. This single-item question served as a proxy measure for sexual orientation and captured sexual attraction only, not identity or behavior.
2) Body image dissatisfaction
(1) Body-part BID scores
Focus-group participants identified nine specific body parts as sources of BID: hair, facial features, skin, muscles, height, body proportion, weight, penis, and body fat. In the survey, participants rated each on a four-point ordinal scale: 1 (very satisfied), 2 (satisfied), 3 (dissatisfied), and 4 (very dissatisfied), to indicate their level of body-part BID.
(2) Overall body-part BID score
The total score (range=9–36) was computed by summing the nine body-part BID scores to indicate overall BID severity. Notably, this nine-body-part BID measure was conceptualized as a formative composite index rather than a reflective latent scale; thus, traditional psychometric properties such as internal consistency were not applicable.
(3) Body-part BID indicators
To estimate the prevalence of body-part BID, each of the nine body-part BID scores was dichotomized into a binary indicator (0=satisfied, 1=dissatisfied).
(4) DCPA indicators
Focus-group participants listed specific DCPA for each of the nine body parts. For example, concerning facial features, men expressed desired changes in “face shape” and “nose shape”. These responses were incorporated into the survey under each relevant body part. Each DCPA was dummy-coded into a binary indicator (0=no, 1=yes).
Sociodemographic characteristics—including age, weight, height, educational level, and employment status—were also collected. Reported weight and height were used to calculate body mass index (BMI) (kg/m2). Notably, following the initial face-to-face focus-group stage for item development, pilot testing was conducted among a separate group of young men before finalizing the survey items to ensure face validity, clarity, and linguistic appropriateness.
4. Data analyses
Based on the nature of the BID variables, four types of analyses were conducted to compare the three sexual orientation subgroups. First, Pearson chi-square tests were used to examine subgroup differences in the dichotomous body-part BID indicators and DCPA indicators. Second, multivariable logistic regression models were estimated to assess associations between sexual orientation and the aforementioned binary body-part BID and DCPA outcomes, adjusting for age and BMI. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported, using heterosexual men as the reference group. Third, the ordinal-scaled body-part BID scores were analyzed using the Kruskal–Wallis test, a nonparametric one-way ANOVA. Fourth, pairwise mean differences in these body-part BID scores (with 95% CIs) were calculated for each subgroup comparison (homosexual vs. heterosexual, bisexual vs. heterosexual, and bisexual vs. homosexual) to evaluate the magnitude and significance of between-group differences. Sociodemographic variables were also analyzed using Pearson chi-square tests, except for age and BMI, which were examined using the Kruskal–Wallis test.
RESULTS
A total of 727 individuals accessed the survey link. Of these, 632 completed and submitted the questionnaire, yielding a completion rate of 86.9%. This rate aligns with published guidance for reporting and interpreting response rates in online surveys using open, self-selected recruitment methods [19].
As shown in Table 1, the study sample consisted of 376 heterosexual men (59.5%), 185 homosexual men (29.3%), and 71 bisexual men (11.2%), totaling 632 men, with a mean age of 23.3 years. The majority of participants were students (64.9%), with more than half of the participants having a college-level education (62.7%). There were no significant subgroup differences in age, employment status, and educational level, but homosexual men had a significantly lower mean BMI (21.79) than heterosexual men (23.06), while bisexual men (22.53) did not significantly differ from either subgroup.
Table 1. Sample characteristics, by sexual orientation.
| Variable | Total (n=632) | Heterosexual (n=376) | Homosexual (n=185) | Bisexual (n=71) | H or χ2 (p) | |
|---|---|---|---|---|---|---|
| Age (y) | 23.33±4.81 | 23.23±4.60 | 23.52±4.70 | 23.35±6.05 | NS | |
| Body mass index (kg/m2) | 22.63±3.75 | 23.06±3.89a | 21.79±3.36a | 22.53±3.64 | 23.03 (<0.001) | |
| Region of Taiwan | 25.75 (<0.001) | |||||
| North | 318 (50.3) | 176 (46.8) | 92 (49.7) | 50 (70.4) | ||
| Central | 110 (17.4) | 60 (16.0) | 46 (24.9) | 4 (5.6) | ||
| South | 204 (32.3) | 140 (37.2) | 47 (25.4) | 17 (23.9) | ||
| Educational levelb | NS | |||||
| Below college | 102 (16.1) | 63 (16.8) | 29 (15.7) | 10 (14.1) | ||
| College | 396 (62.7) | 233 (62.0) | 122 (65.9) | 41 (57.7) | ||
| Above college | 134 (21.2) | 80 (21.3) | 34 (18.4) | 20 (28.2) | ||
| Employment status | NS | |||||
| Unemployed | 57 (9.0) | 35 (9.3) | 18 (9.7) | 4 (5.6) | ||
| Student | 410 (64.9) | 245 (65.2) | 113 (61.1) | 52 (73.2) | ||
| Employed | 165 (26.1) | 96 (25.5) | 54 (29.2) | 15 (21.1) | ||
Values are presented as mean±standard deviation or number (column percentage).
H: Kruskal–Wallis test statistic adjusted for ties, NS: non-significant (if p is not <0.05), χ2: Pearson chi-square test statistic.
aPairwise comparison between heterosexual and homosexual: p<0.05. bParticipants reported their highest educational level (including current enrollment). “College” indicates either current undergraduate enrollment or completion of a bachelor’s degree (and not currently enrolled in a graduate degree program). “Above college” indicates either current graduate student enrollment or completion of a post-graduate degree.
Table 2 shows that more than half of men overall reported body-part BID related to muscles (72.9%), weight (58.9%), body fat (58.7%), and height (50.3%). Bisexual men reported the highest percentages of BID across all body parts. Significant subgroup differences were found in body-part BID related to facial features, skin, muscles, and penis. Heterosexual men reported the lowest BID percentages for these four body parts (21.0%, 41.2%, 69.4%, and 28.5%, respectively), followed by homosexual men (30.8%, 56.8%, 76.2%, and 40.5%, respectively), with bisexual men reporting the highest percentages (36.6%, 57.7%, 83.1%, and 42.3%, respectively). Multivariable logistic regression models, adjusting for age and BMI, are also presented in Table 2 and reveal a consistent pattern: both homosexual and bisexual men exhibited significantly higher odds of BID for these body parts, compared with heterosexual men.
Table 2. Percentages and adjusted odds ratios of body image dissatisfaction with nine specific body parts, by sexual orientation.
| Variable | Total (n=632) | Heterosexual (n=376) | Homosexual (n=185) | Bisexual (n=71) | χ2 (p) | |||
|---|---|---|---|---|---|---|---|---|
| Value | AOR (95% CI) | Value | AOR (95% CI) | |||||
| Hair | 241 (38.1) | 137 (36.4) | Reference | 72 (38.9) | 1.08 (0.75–1.56) | 32 (45.1) | 1.42 (0.85–2.37) | NS |
| Facial features | 162 (25.6) | 79 (21.0) | Reference | 57 (30.8) | 1.68 (1.12–2.52) | 26 (36.6) | 2.18 (1.26–3.75) | 11.31 (0.003) |
| Skin | 301 (47.6) | 155 (41.2) | Reference | 105 (56.8) | 1.88 (1.31–2.70) | 41 (57.7) | 1.96 (1.17–3.27) | 15.28 (<0.001) |
| Muscles | 461 (72.9) | 261 (69.4) | Reference | 141 (76.2) | 1.78 (1.17–2.72) | 59 (83.1) | 2.48 (1.26–4.87) | 7.09 (0.029) |
| Height | 318 (50.3) | 185 (49.2) | Reference | 93 (50.3) | 1.03 (0.72–1.48) | 40 (56.3) | 1.33 (0.80–2.22) | NS |
| Body proportion | 299 (47.3) | 175 (46.5) | Reference | 87 (47.0) | 1.24 (0.86–1.79) | 37 (52.1) | 1.37 (0.81–2.32) | NS |
| Weight | 372 (58.9) | 221 (58.8) | Reference | 102 (55.1) | 1.27 (0.86–1.89) | 49 (69.0) | 2.05 (1.13–3.72) | NS |
| Penis | 212 (33.5) | 107 (28.5) | Reference | 75 (40.5) | 1.95 (1.33–2.85) | 30 (42.3) | 1.96 (1.15–3.32) | 10.84 (0.004) |
| Body fat | 371 (58.7) | 218 (58.0) | Reference | 107 (57.8) | 1.54 (1.03–2.30) | 46 (64.8) | 1.75 (0.97–3.14) | NS |
Values are presented as number (column percentage).
The numbers in this table indicate the count of participants who answered “dissatisfied” or “very dissatisfied” for the corresponding specific body part. The percentages are reported for participants within their respective sexual orientation subgroup. All AORs controlled for age and body mass index.
χ2: Pearson chi-square test statistic, NS: non-significant (if p is not <0.05), AOR: adjusted odds ratio, CI: confidence interval.
Table 3 presents the nine ordinal-scaled body-part BID scores (range=1–4) and the overall body-part BID score (range=9–36). Significant subgroup differences were observed for facial features, skin, muscles, penis, and the overall score. Pairwise mean difference analyses further showed that both homosexual and bisexual men reported significantly higher BID scores for skin, muscles, and the overall score than heterosexual men. In addition, homosexual men reported a significantly higher BID score for penis than heterosexual men, with a mean difference of 0.19 (95% CI: 0.04–0.34).
Table 3. Body image dissatisfaction scores for nine specific body parts: means and pairwise mean differences, by sexual orientation.
| Variable | Total | Heterosexual | Homosexual | Bisexual | H (p) | Mean difference (95% CI) | ||
|---|---|---|---|---|---|---|---|---|
| M (SD) | M (SD) | M (SD) | M (SD) | Homosexual-heterosexual | Bisexual-heterosexual | Bisexual-homosexual | ||
| Hair | 2.37 (0.68) | 2.35 (0.68) | 2.39 (0.65) | 2.44 (0.71) | NS | 0.04 (-0.10–0.19) | 0.09 (-0.13–0.30) | 0.05 (-0.19–0.27) |
| Facial features | 2.22 (0.59) | 2.16 (0.55) | 2.28 (0.62) | 2.34 (0.67) | 8.98 (0.011) | 0.12 (0.00–0.25) | 0.18 (0.00–0.36) | 0.06 (-0.14–0.25) |
| Skin | 2.49 (0.73) | 2.39 (0.71) | 2.63 (0.70) | 2.66 (0.83) | 17.82 (<0.001) | 0.24 (0.09–0.40)* | 0.27 (0.05–0.50)* | 0.03 (-0.21–0.27) |
| Muscles | 2.88 (0.70) | 2.77 (0.68) | 2.98 (0.70) | 3.07 (0.76) | 17.91 (<0.001) | 0.21 (0.06–0.36)* | 0.30 (0.08–0.51)* | 0.09 (-0.15–0.32) |
| Height | 2.56 (0.82) | 2.53 (0.82) | 2.62 (0.80) | 2.56 (0.87) | NS | 0.09 (-0.09–0.26) | 0.03 (-0.22–0.29) | -0.05 (-0.33–0.22) |
| Body proportion | 2.48 (0.74) | 2.46 (0.71) | 2.51 (0.75) | 2.54 (0.83) | NS | 0.05 (-0.11–0.21) | 0.08 (-0.15–0.30) | 0.03 (-0.22–0.27) |
| Weight | 2.70 (0.77) | 2.69 (0.79) | 2.67 (0.71) | 2.86 (0.83) | NS | -0.02 (-0.19–0.15) | 0.17 (-0.72–0.41) | 0.19 (-0.07–0.45) |
| Penis | 2.29 (0.70) | 2.21 (0.69) | 2.41 (0.66) | 2.38 (0.78) | 11.94 (0.003) | 0.19 (0.04–0.34)* | 0.17 (-0.05–0.38) | -0.03 (-0.26–0.21) |
| Body fat | 2.66 (0.76) | 2.66 (0.76) | 2.65 (0.76) | 2.68 (0.82) | NS | -0.01 (-0.18–0.15) | 0.02 (-0.23–0.25) | 0.03 (-0.23–0.28) |
| Overall body image dissatisfaction | 22.65 (3.78) | 22.23 (3.70) | 23.15 (3.57) | 23.52 (4.37) | 12.76 (0.002) | 0.91 (0.10–1.72)* | 1.29 (0.12–2.45)* | 0.38 (-0.88–1.63) |
The body image dissatisfaction score for each specific body part ranges from 1 (very satisfied) to 4 (very dissatisfied), with a higher score indicating more dissatisfaction. The overall body image dissatisfaction score is calculated by summing the scores of the nine specific body parts (range=9–36), with a higher score indicating more severe body image dissatisfaction.
M: mean, SD: standard deviation, H: Kruskal–Wallis test statistic adjusted for ties, CI: confidence interval.
*Indicates statistical significance at p<0.05.
Table 4 presents the percentages of 27 DCPA indicators that differed significantly across sexual orientation subgroups. AORs with 95% CIs—adjusting for age and BMI—are also reported in Table 4 as effect size measures to convey the magnitude and direction of associations, not merely their statistical significance. Homosexual and bisexual men showed significantly higher odds than heterosexual men in 25 and 20 of these DCPA outcomes, respectively. Notably, the two outcomes—desire for an upward penile curve and a larger glans—were significant among bisexual men, but not among homosexual men. Specifically, 12.8% of heterosexual men desired an upward penile curve, compared with 16.8% of homosexual and 23.9% of bisexual men; 22.6% of heterosexual men desired a larger glans, compared with 24.3% of homosexual and 36.6% of bisexual men. Bisexual men had significantly higher odds than heterosexual men for both outcomes, with AOR=2.18 (95% CI: 1.17–4.08) and AOR=2.04 (95% CI: 1.17–3.44), respectively.
Table 4. Percentages and adjusted odds ratios of desired changes in physical attributes, by sexual orientation.
| Variable | Total (n=632) | Heterosexual (n=376) | Homosexual (n=185) | Bisexual (n=71) | χ2 (p) | ||||
|---|---|---|---|---|---|---|---|---|---|
| n (Col. %) | n (Col. %) | n (Col. %) | AOR (95% CI) | n (Col. %) | AOR (95% CI) | ||||
| Hair | |||||||||
| Hairstyle | 210 (33.2) | 100 (26.6) | Reference | 80 (43.2) | 2.16 (1.48–3.16) | 30 (42.3) | 2.03 (1.19–3.46) | 18.43 (<0.001) | |
| Facial features | |||||||||
| Face shape | 166 (26.3) | 78 (20.7) | Reference | 65 (35.1) | 2.12 (1.42–3.16) | 23 (32.4) | 1.84 (1.05–3.22) | 14.81 (0.001) | |
| Nose shape | 131 (20.7) | 60 (16.0) | Reference | 50 (27.0) | 1.99 (1.29–3.07) | 21 (29.6) | 2.23 (1.25–3.99) | 13.06 (0.001) | |
| Thickness of lips | 112 (17.7) | 53 (14.1) | Reference | 44 (23.8) | 1.79 (1.34–2.82) | 15 (21.1) | 1.59 (0.83–3.02) | 8.62 (0.013) | |
| Skin | |||||||||
| Darker | 86 (13.6) | 26 (6.9) | Reference | 44 (23.8) | 4.47 (2.62–7.64) | 16 (22.5) | 3.99 (2.00–7.96) | 35.44 (<0.001) | |
| Fewer wrinkles | 78 (12.3) | 28 (7.4) | Reference | 39 (21.1) | 3.20 (1.88–5.43) | 11 (15.5) | 2.23 (1.05–4.74) | 22.04 (<0.001) | |
| Fewer freckles | 52 (8.2) | 22 (5.9) | Reference | 22 (11.9) | 2.55 (1.35–4.83) | 8 (11.3) | 2.20 (0.93–5.20) | 6.97 (0.031) | |
| More body hair | 56 (8.9) | 13 (3.5) | Reference | 32 (17.3) | 6.14 (3.10–12.14) | 11 (15.5) | 5.23 (2.23–12.24) | 33.77 (<0.001) | |
| Smoother | 278 (44.0) | 150 (39.9) | Reference | 95 (51.4) | 1.64 (1.14–2.35) | 33 (46.5) | 1.32 (0.79–2.21) | 6.81 (0.033) | |
| Muscles | |||||||||
| Arms | 299 (47.3) | 143 (38.0) | Reference | 117 (63.2) | 2.75 (1.90–3.98) | 39 (54.9) | 1.97 (1.20–3.29) | 33.48 (<0.001) | |
| Chest | 333 (52.7) | 166 (44.1) | Reference | 122 (65.9) | 2.52 (1.74–3.66) | 45 (63.4) | 2.22 (1.31–3.76) | 27.30 (<0.001) | |
| Shoulders | 169 (26.7) | 75 (19.9) | Reference | 71 (38.4) | 2.38 (1.60–3.53) | 23 (32.4) | 1.89 (1.08–3.30) | 22.81 (<0.001) | |
| Back | 150 (23.7) | 73 (19.4) | Reference | 58 (31.4) | 1.97 (1.31–2.97) | 19 (26.8) | 1.54 (0.86–2.77) | 10.17 (0.006) | |
| Buttocks | 195 (30.9) | 91 (24.2) | Reference | 76 (41.1) | 2.54 (1.72–3.76) | 28 (39.4) | 2.19 (1.28–3.77) | 19.32 (<0.001) | |
| Abdomen | 469 (74.2) | 263 (69.9) | Reference | 147 (79.5) | 2.11 (1.36–3.26) | 59 (83.1) | 2.41 (1.23–4.74) | 9.17 (0.010) | |
| Waist | 231 (36.6) | 118 (31.4) | Reference | 85 (45.9) | 2.39 (1.62–3.52) | 28 (39.4) | 1.59 (0.92–2.73) | 11.63 (0.003) | |
| Thighs | 236 (37.3) | 123 (32.7) | Reference | 79 (42.7) | 1.80 (1.23–2.62) | 34 (47.9) | 2.05 (1.21–3.47) | 9.09 (0.011) | |
| Calves | 170 (26.9) | 75 (19.9) | Reference | 72 (38.9) | 2.81 (1.88–4.20) | 23 (32.4) | 1.99 (1.13–3.49) | 23.93 (<0.001) | |
| Penis | |||||||||
| Upward curve | 96 (15.2) | 48 (12.8) | Reference | 31 (16.8) | 1.42 (0.87–2.34) | 17 (23.9) | 2.18 (1.17–4.08) | 6.29 (0.043) | |
| Straighter | 83 (13.1) | 36 (9.6) | Reference | 34 (18.4) | 2.11 (1.26–3.52) | 13 (18.3) | 2.11 (1.05–4.22) | 10.30 (0.006) | |
| Larger glans | 156 (24.7) | 85 (22.6) | Reference | 45 (24.3) | 1.13 (0.75–1.72) | 26 (36.6) | 2.04 (1.17–3.44) | 6.33 (0.042) | |
| Darker | 24 (3.8) | 6 (1.6) | Reference | 10 (5.4) | 3.89 (1.37–11.03) | 8 (11.3) | 8.23 (2.75–24.69) | 17.14 (<0.001) | |
| Lighter | 56 (8.9) | 20 (5.3) | Reference | 31 (16.8) | 3.52 (1.93–6.43) | 5 (7.0) | 1.33 (0.48–3.69) | 20.41 (<0.001) | |
| Larger testicles | 70 (11.1) | 17 (4.5) | Reference | 37 (20.0) | 5.84 (3.14–10.84) | 16 (22.5) | 6.46 (3.07–13.62) | 40.83 (<0.001) | |
| Body fat | |||||||||
| More fat in chest | 71 (11.2) | 30 (8.0) | Reference | 31 (16.8) | 1.87 (1.08–3.27) | 10 (14.1) | 1.74 (0.79–3.85) | 10.23 (0.006) | |
| Less fat in arms | 123 (19.5) | 63 (16.8) | Reference | 39 (21.1) | 2.14 (1.30–3.54) | 21 (29.6) | 2.80 (1.48–5.30) | 6.70 (0.035) | |
| Less fat in calves | 123 (19.5) | 63 (16.8) | Reference | 39 (21.1) | 1.95 (1.20–3.19) | 21 (29.6) | 2.59 (1.39–4.84) | 6.70 (0.035) | |
The numbers in this table indicate the count of participants who answered “yes” for the corresponding desired physical attribute change. The percentages are reported for participants within their respective sexual orientation subgroup. All AORs controlled for age and body mass index.
Col. %: column percentage, χ2: Pearson chi-square test statistic, AOR: adjusted odds ratio, CI: confidence interval.
DISCUSSION
This study compared the prevalence and levels of BID for nine body parts, as well as prevalence of DCPA, among cisgender heterosexual, homosexual, and bisexual men in Taiwan. It is among the first to extensively evaluate BID concerns among Asian men and differentiate between bisexual and homosexual individuals in subgroup comparisons.
Notably, while bisexual men generally exhibited similar BID patterns as their homosexual peers, showing higher BID than heterosexual men, our DCPA analysis revealed that among the 27 DCPA items with significant subgroup differences, nine were most endorsed by bisexual men. Specifically, compared with heterosexual men, two DCPA (an upward curve of the penis and a larger glans) showed significantly higher odds only among bisexual men, but not among homosexual men. These particular distinctions in desired changes, which highlight unique BID concerns among bisexual men, may reflect pressure to conform to a heterosexual-homosexual dichotomy, underscoring the importance of understanding bisexual men’s unique BID experiences. These findings pave the way for targeted interventions to enhance positive body image and well-being among Asian men.
1. Genetic predispositions and perceived attractiveness: focus on abdominal and chest muscles
Our DCPA analysis identified muscularity concerns among men, particularly in the abdominal and chest muscles, with more than half expressing a desire for improvement. Genetic factors, such as East Asians’ predisposition to higher abdominal fat [20], may drive these concerns, as observed in our Taiwanese sample. Additionally, a lower waist-to-chest ratio, reflecting a V-shaped torso, has been associated with men’s perceived attractiveness, fitness, and dominance [21]. These traits may explain why homosexual and bisexual men who face these societal pressures related to masculine ideals and appearance reported significantly higher BID than heterosexual men. Therefore, targeted body image health education can effectively address these concerns across different populations.
2. Intersection of body fat and muscularity concerns: focus on the chest, calves, and arms
Homosexual and bisexual men exhibited higher DCPA across most muscle groups than heterosexual men, with homosexual men reporting the highest DCPA for all but the abdomen and thighs, where bisexual men showed more concern. Notably, homosexual men had more than twice the odds of desiring changes in the chest, calves, arms, buttocks, and shoulders, compared with heterosexual men. The emphasis on calves aligns with documented BID trends in Asian cultures, particularly among women seeking calf-slimming procedures [22]. U.S. LGBTQ-friendly plastic surgeons also report a growing demand among gay men for pectoral and calf implants, as well as “anal rejuvenation” procedures [23], a trend partly reflected in our study, where homosexual and bisexual men also showed significantly higher BID for chest muscles and calves. Additionally, although we did not assess anal-related concerns specifically, our findings showed that sexual minority men had more than twice the odds of endorsing buttock-related DCPA compared with heterosexual men, suggesting further scrutiny in future studies.
While body fat attracted less attention than muscularity concerns, Taiwanese men desired more fat in the chest and less in the calves and arms, highlighting these areas as recurring sources of BID, particularly for sexual minority men. These preferences could make sexual minority men more vulnerable to exploitation in the aesthetic surgery industry, underscoring the need for ongoing monitoring of trends and targeted educational campaigns.
3. Desired changes in facial features: focus on the face shape, nose shape, and thickness of lips
Previous research on white men suggested that homosexual men tend to have a blend of feminine and masculine features, such as wider, shorter faces, and more rounded jaws, compared with heterosexual men [24]. However, these studies were limited in scope, focusing primarily on small, white samples. More recent research indicates that most Chinese participants prefer features like an oval face, tapered jaw, straight concave nose, and full lips with a Cupid’s bow [25]. Our study similarly identified desired changes in face shape, nose shape, and lip thickness, with notable differences among sexual orientation subgroups. These variations likely reflect the pressure sexual minority men feel to conform to Asian beauty standards.
Although sexual minority men, particularly in the East, are increasingly utilizing cosmetic surgery, comprehensive data on these populations remain scarce, as physicians rarely inquire about sexual orientation. With rising interest in facial procedures, further research and informed guidelines are necessary to ensure these groups are not disproportionately vulnerable to industry exploitation.
4. Desired skin attributes: focus on smoothness and darker skin tone
Skin smoothness emerged as the primary concern, with 39.9% to 51.4% of men desiring smoother skin. Other attributes, such as skin darkness, wrinkles, freckles, and body hair, were less important for heterosexual men, with DCPA percentages in the single digits. However, homosexual and bisexual men had approximately two to six times higher odds of desiring changes in these attributes than heterosexual men. Notably, fewer wrinkles appeared to be a greater concern for homosexual (21.1%; AOR=3.20) than bisexual (15.5%; AOR=2.23) men, reflecting nuanced differences in DCPA despite broader similarities.
A study on Asian skin trends confirmed the high value placed on clear, fair, and youthful skin [26], aligning with our findings. Homosexual and bisexual men, however, showed a stronger preference for darker (tanner) skin, contradicting traditional Asian beauty standards. This may reflect “queer hybridity” [27], with Western norms (e.g., tanning associated with fitness and muscle definition) influencing the non-West. This preference is notable given men’s higher melanoma risk than women [28]. These findings highlight the complex interplay of cultural influences on beauty ideals among Taiwanese LGBTQ communities.
5. Differences in genital BID and DCPA across sexual orientations
While previous studies have focused on penis size, fewer have explored attributes such as shape, glans, and scrotum. Researchers suggest that penis size symbolizes masculinity [16], causing anxiety and BID even within normal ranges [29]. Approximately one-third of men expressed genital BID, with sexual minority men reporting more desired changes.
Notably, bisexual men exhibited the highest DCPA percentages for an upward curve, a larger glans, larger testicles, and a darker penis, with more than two to eight times higher odds of desiring changes in these four penile attributes than heterosexual men. Approximately one in four bisexual men reported DCPA for an upward curve, which may help with insertability—a preference shown in sex toys among women [30]. The most desired change was an increase in glans size, with one-quarter of men and over one-third of bisexual men indicating this preference, similar to sex toys designed for effectively stimulating the prostate and female organs.
While under 5% of heterosexual men desired larger testicles, about one-fifth of homosexual and bisexual men expressed this preference. The frequent mention of testicles in personal ads [31] and increasing popularity of scrotum tightening procedures highlight evolving aesthetic preferences [32]. These findings underscore the importance of genital attributes in men’s BID, reflecting local LGBTQ beauty norms and the struggles, particularly for bisexual men, to navigate societal expectations.
6. Limitations and future directions
This study has several limitations that suggest opportunities for future research. First, we recruited participants through an online forum popular among Taiwanese youth. This method ensured participant anonymity and facilitated access to a diverse population, including sexual minority men. However, recruiting from a text-based, bulletin board–style forum may have resulted in a sample skewed toward more techsavvy individuals. Although our inclusion criteria allowed for demographic variation, the sample was predominantly composed of students (64.9%), likely reflecting the forum’s user base. This may limit the generalizability of the findings to broader populations. Future studies may benefit from diversifying recruitment channels, including different types of social media platforms, to enhance external validity and secure a larger bisexual subsample for more detailed comparisons.
Second, we defined sexual orientation solely by sexual attraction, which is a common approach but does not account for identity or behavior. This single-item measure introduces a potential for misclassification bias, as individuals’ attractions may not perfectly align with their self-identified orientation or sexual behaviors. Such misclassification would likely blur distinctions between subgroups, making them appear more similar than they are. Therefore, the observed differences in our results are likely conservative, and the actual differences may be more pronounced. While a behaviorally defined approach might offer further insights, many young Taiwanese men may still be sexually inactive, which would make classification based on behavior a less viable alternative. Future research could explore more comprehensive or context-specific methods for assessing sexual orientation in this demographic.
Third, while our exploratory approach addressed the literature gap in understanding DCPA by sexual orientation, the specific design of our BID measure warrants careful consideration. As a novel instrument, the nine-body-part BID measure was conceptualized as a formative composite index, rendering traditional psychometric properties inapplicable. Furthermore, the deliberate use of a four-point forced-choice scale (without a neutral option) for BID assessment was based on focus-group insights indicating that this format could encourage more authentic self-reflection in a sensitive cultural context. While this approach aimed to enhance the detection of genuine disparities by discouraging neutral default responses, future research could explore the implications of different response formats and further develop context-specific psychometric considerations for such composite measures.
Lastly, studying the full diversity of the LGBTQ community is challenging. Future research should explore more subgroups within the LGBTQ spectrum, recognizing their unique body image concerns. Additionally, further exploration is needed to examine how BID affects various aspects of men’s health and well-being (e.g., self-esteem, sexual functioning, psychosocial distress). Addressing these limitations will advance the understanding of BID among sexual orientation subgroups and inform more inclusive health interventions.
CONCLUSIONS
In conclusion, this research underscores the importance of understanding BID and DCPA among Taiwanese men, particularly considering the perspectives of different sexual orientations. The findings reveal specific body parts and various physical attributes contributing to BID among heterosexual, homosexual, and bisexual men, emphasizing the significance of targeted interventions and support for the diverse needs of LGBTQ populations. Moreover, it draws attention to the potential risks of exploitation within the cosmetic surgery industry, particularly for homosexual and bisexual men, and calls for further research and strategies to ensure the well-being and ethical treatment of these populations. Despite Taiwan’s progressive stance on LGBTQ rights, the higher suicide rate among young LGBTQ men highlights the continued need for research in this area. The insights gained from this study may have broader implications for other Asian countries, potentially saving lives and improving health outcomes within the LGBTQ community.
Acknowledgements
None.
Footnotes
Conflict of Interest: The authors have nothing to disclose.
Funding: Preparation of this manuscript was supported in part by the National Science and Technology Council, Taiwan (formerly, Ministry of Science and Technology) (grants: MOST 109-2410-H-002-108-, MOST 108-2410-H-002-194-, MOST 107-2410-H-002-214-, and MOST 105-2410-H-002-143-MY2 [PI: Dr. Jiun-Hau Huang]). The funding source had no involvement in any of the following: the study design; the collection, analysis, and interpretation of the data; the writing of the article; and the decision to submit the article for publication.
- Conceptualization: JHH.
- Data curation: JHC.
- Formal analysis: JHH, JHC.
- Funding acquisition: JHH.
- Investigation: JHH.
- Methodology: JHH.
- Project administration: JHH.
- Supervision: JHH.
- Validation: JHH.
- Visualization: JHH, JHC.
- Writing – original draft: JHH, MW.
- Writing – review & editing: all authors.
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