that threaten to reveal their perceived deficiency of size or muscularity. Roughly half of patients have poor or no insight that these perceptions are unrealistic. Patient histories reveal elevated rates of diagnoses of other mental disorders, including eating disorders, mood disorders, anxiety disorders, and substance use disorder, as well as elevated rates of suicide attempts. Risk factors Although muscle dysmorphia's development is unclear, several risk factors have been identified. Trauma and bullying Versus the general population, persons manifesting muscle dysmorphia are more likely to have experienced or observed traumatic events like sexual assault or domestic violence, or to have sustained adolescent bullying and ridicule for actual or perceived deficiencies such as smallness, weakness, poor athleticism, or intellectual inferiority. Increased body mass may seem to reduce the threat of further mistreatment. Sociopsychological traits Low self-esteem is associated with higher levels of body dissatisfaction and of muscle dysmorphia. Increased body size or muscularity may seem to enhance the masculine identity. Media exposure As Western media emphasize physical attractiveness, some marketing campaigns now exploit male body-image insecurities. Since the 1980s, the number of fitness magazines and of partially undressed, muscular men in advertisements have increased. Such media provoke bodily comparisons and pressure individuals to conform, yet increase the gap between men's perceptions of their own muscularity versus their desired muscularity. In college-aged men, a strong predictor of a muscularity quest is internalization of the idealized male bodies depicted in media. Athletic participation Athletes tend to share some psychological factors that may predispose to muscle dysmorphia, factors including high levels of competitiveness, need for control, and perfectionism, and athletes tend to be more critical of their own bodies and body weight. Athletes who also fail to their sports performance goals may escalate efforts to modify their builds, efforts that overlap those of muscle dysmorphia. Involvement in sports where size, strength, or weight, whether higher or lower, imply competitive advantage associates with muscle dysmorphia. Athletic ideals reinforce the social ideal of muscularity. Conversely, those already disposed to muscle dysmorphia may be more likely to participate in such sports. Sexual orientation It has been observed that men who have sex with men (MSM) have a unique relationship with the development of muscle dysmorphia symptoms. MSM are at increased risk for experiencing internalized heterosexism, which can lead to dissatisfaction with one's body and the internalizing of standards for attractiveness. Men who conform to conventional ideals of masculinity