In his life, Clayton Echard has held several roles that are classically tied to his gender identity of male, including college athlete, NFL player, and star of The Bachelor. And by all outward measures, the 29-year-old’s body and appearance seems to fall within mainstream society’s idealized norm of the masculine form. On the inside, though, Echard says he’s always felt differently. Since seventh grade, he has struggled with body dysmorphic disorder (BDD), but he never spoke up about it. He’s since realized that the reason he internalized his BDD for so long is due to the toxic masculinity that runs rampant in the elite athletic and media communities, which might cast him as not being “masculine” enough if he spoke up.

“I would wake up in the morning, look in the mirror, and be flooded with these negative thoughts about myself: ‘You look terrible, you need to get in better shape,’” says Echard, whom I spoke with in relation to his partnership with the Anxiety & Depression Association of America (ADAA). These kinds of thoughts are common with body dysmorphic disorder, which is a mental-health condition that presents as being obsessively concerned with perceived flaws or defects in one’s own body to the point that it disrupts life.

“I would wake up in the morning, look in the mirror, and be flooded with these negative thoughts about myself: ‘You look terrible, you need to get in better shape.’” —Clayton Echard

As with most mental-health conditions, the causes of BDD are varied and complex, though it’s thought that a combination of biological and environmental factors can fuel its categorical cognitive distortions.

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One of the big items on that list of contributing causes is childhood trauma. “Approximately 80 percent of people with BDD have experienced some form of childhood maltreatment,” says therapist Scott Granet, LCSW, director of the OCD-BDD Clinic of Northern California and member of the ADAA. “This includes childhood neglect, physical and sexual abuse, as well as bullying and excessive teasing.” And in many cases, pressure from peers or social media to appear a certain way only piles onto existing body dysmorphic thoughts.

As a high-schooler, Echard wondered if anyone else was experiencing negative feelings similar to his, but he didn’t vocalize his thoughts out of fear of turning himself into a target for bullies. At the time, the conversions he had with classmates and other male-identifying people in his life were “basically along the lines of, ‘We’re men, and men don’t talk about their feelings, and they don’t struggle with emotions. That’s a female problem’,” he says.

Body dysmorphic disorder, in particular, is often mischaracterized as a “female disorder” for the simple fact that the symptoms involve appearance, and women have perhaps historically been more obviously objectified for theirs than men have. But, in fact, a nationwide survey from 2008 found that the percentage of female-identifying people with BDD was 2.5, while the percentage of male-identifying people with the condition was 2.2—which is not significantly less. A separate study found that slightly more men may actually have BDD than women, with numbers clocking in at 1.2 percent for men and 1 percent for women.

“Men don’t talk about body dysmorphic disorder, so it perpetuates this idea that it’s non-existent for them.” —Echard

And yet, from Echard’s point of view, it seems that “men don’t talk about BDD, so it perpetuates this idea that it’s nonexistent for them.” That was particularly the case for him on his college football team, which was a hotbed for toxic masculinity. “With football, it was always about presenting this image of being a strong macho man and living up to this hype of, ‘Oh we’re a different kind of breed,’” he says.

That very image can worsen body dysmorphic disorder, too. “The stereotypical muscular physique of attractive men seen in movies, on TV, in magazines, and especially on social media creates an unrealistic standard,” says Granet. “Many men pursue that and may not recognize that the obsessive nature of their pursuit is likely part of a serious psychiatric problem and not simply a desire to look better.”

And even if folks do recognize that the instinct isn’t doing their mental health any favors, they might not seek treatment due to “cultures that stress the importance of machismo or view pursuing therapy as a sign of weakness,” says Granet.

Upon recognizing his symptoms, Echard didn’t initially seek treatment for his case of BDD, either. Instead, he turned to the internet in search of an outlet or a community with which he could share his feelings, when his football teammates wouldn’t suffice. “I started to educate myself, and I realized that there was a term for what I was feeling, which already helped,” he says. “I began to understand that I wasn’t alone and that what I was struggling with was something that others struggle with, too, including men.”

Though he was on the right path toward healing his BDD by the time he starred on The Bachelor, Echard says he regressed upon the show’s airing. “With The Bachelor, you’re supposed to be the most sought-after man in America, which comes with the expectations that you have your whole life figured out and that you don’t have any mental-health issues—and I really felt that pressure on me,” he says.

Since then, he’s had numerous therapy sessions and credits them with much of his current success managing the condition. With his newfound platform with the ADAA, it’s his goal to help others in his position feel empowered to do the same. “I’m trying to show people that, ‘Hey, I’m getting help for this, and I’m speaking up about this, and I am no less of a man for doing so,’” he says. “I also want people to know that when you open up, you don’t ruin connections, you actually build them.”