The use of performance-enhancing drugs may be tied to depression and body image issues among adolescent boys, according to new research published in December.

Aaron Blashill, clinical health psychologist at Massachusetts General Hospital and psychology professor in the Department of Psychiatry at Harvard Medical School, led two studies in 2013 in which teen boys who saw themselves as underweight reported higher levels of depression and were more likely to use performance-enhancing steroids.

The first study focused on body image distortion as a common source of depression among teen boys and showed that participants who saw themselves as underweight reported the highest levels of depression. The group of boys who identified themselves as overweight or obese did not report any elevated levels of depression, a result that Blashill said surprised the research team.

“What it tells me is that what is more important than actual weight is perception of one’s weight, and that if you compare making distortions in the underweight direction or in the overweight direction, at least for boys, it’s the underweight distortion[s] that are driving depression,” Blashill said.

The second study examined how boys’ body image is related to performance-enhancing behaviors by analyzing their levels of victimization such as being bullied or teased, depressive symptoms and anabolic-androgenic steroid use. The study found that boys who regarded themselves as underweight used greater amounts of steroids than other boys their age.

“Skinny boys or boys who are underweight are victimized at higher levels, and they may be trying steroids or other performance-enhancing drugs as a way to defend themselves and to evade the bullying that they’re receiving,” Blashill said.

The first study’s results were based on data taken from the National Longitudinal Study of Adolescent Health and the boys’ reported depressive symptoms were based on the Center for Epidemiological Studies Depression Scale. Data obtained from the 2009 national Youth Risk Behavior Survey was used in the second study.

Blashill said he thinks the connection between bullying and boys who see themselves as underweight has to do with Western culture’s emphasis on men being lean and muscular. There is an intimate relationship between muscularity and masculinity, he said, because Western culture has popularized the belief that muscularity is an explicit representation of masculinity. Teen boys who perceive themselves to be lacking the “ideal” muscular physique may feel that their masculinity is threatened, he said.

“Boys who view themselves to not be of a larger, more muscular build [may be] thinking, ‘You know, I’m not really fitting [in] with these ideals this society proposes for what men should look like; maybe I’m not masculine enough either,’” Blashill said.

Alison Field, associate professor of Pediatrics at Harvard Medical School, published a study in August 2005 examining how this “ideal” body image affects teen boys and girls. The study found that adolescent boys were more likely than adolescent girls to try to gain weight, and 5 percent of boys used products to improve appearance or muscles. The research team focused on media as a promoter of the “ideal” body.

Participants were asked about their physical activity, weight and shape concerns, media exposure and use of performance enhancing drugs. The study found that the hours per week of watching television, the number of sports watched on television and the types of sports watched were unrelated to weekly use of performance-enhancing products.

“We don’t tend to disentangle screen media very well,” Field said. “So it looks like print media has a bigger effect, but I think the jury’s still out on that.”

Society and the home environment may also largely impact how teen boys view body image, according to psychiatrist Robin Shapiro.

“There’s the social impact with whatever is going on at school or their social groups,” Shapiro said. “And then parents at home. I think those are all equally important.”

Normalizing these issues among teen boys is a beneficial way to start combating their distorted views of body image, Shapiro said.

“I think providing support … and pointing out that what we see in the media is not reality,” Shapiro said.