Most people are by now familiar with the concept of body dysmorphia, or an individuals obsession with what they perceive as defectiveness or inadequacy in their physical form. For the longest time, both those who spoke out against it and those who suffered from it were believed to be primarily women, pushed to the brink in a quest to achieve the idealistic physical perfection pushed upon them by society and the media. It turns out they’re not alone: Body image issues are linked to increased depression and steroid use in teenage boys, according to studies by Aaron Blashill, PhD, staff psychologist at Massachusetts General Hospital.

The danger lies not with boys who believe they’re too large or fat, but rather too scrawny. At greatest risk are teenage boys who have these issues but are actually a healthy size, even more so than boys who believe themselves to be too fat. Blashill’s research was based on two large, nationally representative samples of teenage boys in the U.S. The first sample included 2,139 boys who were about 16 years old in 1996 at the beginning of the study and were followed for 13 years.

Of those who perceived themselves as too skinny and reported being victims of bullying, not only were they more likely to use steroids and feel more depressed than other boys their age, but that depression was more likely to carry into adulthood as well.

Boys who perceived themselves as very underweight, but actually were average weight or higher, reported the highest level of depressive symptoms. These findings remained constant across the span of the study, which ended when the participants were close to 30 years old.

“These studies highlight the often underreported issue of distorted body image among adolescent boys,” said Blashill. “Teenage girls tend to internalize and strive for a thin appearance, whereas teenage boys tend to emphasize a more muscular body type. We found that some of these boys who feel they are unable to achieve that often unattainable image are suffering and may be taking drastic measures.”

In another study, using data came from a 2009 nationally representative survey of 8,065 ninth- through 12th-grade boys in the U.S., Blashill found similar results, including 4% reporting steroid usage and 3% rating themselves as “very underweight.” Unsurprisingly, those who perceived themselves as underweight were more frequently targeted for bullying, possibly leading to steroid use, Blashill said.

Blashill also suggests that healthcare professionals should be mindful of the possibility of steroid use when working with boys who are bullied because of what they believe to be their body weight.

“Unfortunately, there is little evidence-based research on effective therapies for steroid use among adolescent boys,” he said. “However, cognitive-behavioral therapy has proven to be effective for body image concerns and could be helpful for boys considering using or already using steroids.”