Stop Confusing Gender Dysphoria With Body Dysmorphia Already

In Depth

Conflation of gender dysphoria and body dysmorphia seems hard to imagine to those who are very well aware of both of these terms. However, it seems to be a fairly common point of confusion in articles about transgender individuals and extremely prevalent in the comments sections of other transgender related articles.

While both serious issues, they are very different. As surprising as it is, even sometimes sources trying to support transgender individuals get it wrong. And the usage of a combined term almost always accompanies other types of errors when speaking about transgender individuals, such as the use of incorrect pronouns or a refusal to recognise the difference between sex and gender. Indeed, because it is so prevalent, especially in tabloid media, it’s possible to see it or hear it used by transgender people themselves who are unaware of how that both undermines the reality of gender dysphoria and marginalises the experience of those who suffer from body dysmorphia. This is a lose-lose situation.

In order to understand the differences, and why it is a harmful conflation for both groups of individuals, those with gender dysphoria and those with body dysmorphia, we must look at the differences between the definitions of the two.

According to Britain’s National Health Service, the definition of the latter is as follows:

Body dysmorphic disorder (BDD), or body dysmorphia, is an anxiety disorder that causes sufferers to spend a lot of time worrying about their appearance and to have a distorted view of how they look.

I want the highlight that very last clause, “have a distorted view of how they look.” This is crucial to understanding why even the physical aspects of gender dysphoria (sometimes called sex dysphoria to differentiate those aspects from the gender expression and presentation aspects) cannot be compared with body dysmorphia.

To be consistent, I will use NHS’s definition of gender dysphoria as well:

Gender dysphoria is a condition where a person experiences discomfort or distress because there is a mismatch between their biological sex and gender identity…This mismatch between sex and gender identity can lead to distressing and uncomfortable feelings that are called gender dysphoria. Gender dysphoria is a recognised medical condition, for which treatment is sometimes appropriate. It is not a mental illness.

Emphasis mine. With the changes in the new Diagnostic Standards Manual (version V), there has been the removal of disorder in the title of the entry concerning gender identity (which in previous versions was labeled gender identity disorder). Although there are still hold outs, the vast majority of medical professionals and mental healthcare providers agree: if a person with gender dysphoria is having issues with mental illness, which is not uncommon, gender dysphoria is not the underlying cause. Rather, it is society’s unwillingness to treat individuals with gender dysphoria with care, dignity, and respect (including necessary medical treatment, when appropriate) which can lead to maladjustment. A great many individuals with gender dysphoria are considered perfectly well-adjusted, the stressors of gender dysphoria being comparable to other stressors associated with any serious medical condition.

Although my experiences with mental healthcare professionals as a child were terrible (none of them considered gender dysphoria as a possibility. They misdiagnosed me with anxiety disorders and put me on medications briefly which did not work for obvious reasons), as an adult I have received three (2003, 2005, and 2013) evaluations from psychiatric professionals attesting that I am not just well-adjusted for a person with gender dysphoria, but rather I am well-adjusted in general. My previous mental healthcare providers either did not know how to recognise children with gender dysphoria or simply did now know how to deal with them. They tried treating me for something which wasn’t wrong.

It is worth taking the time to mention that in the past, I have justifiably been called out for some of my commentary on this issue and my choice of framing because to some it has come off as ableist. I recognise that my own issues with the mental healthcare system (until very recently) have sometimes colored my phrases. I have, indeed, been ableist. In my reaction to being labeled mentally ill, and my rush to explain why I, personally, am not, I have often inadvertently thrown those suffering from body dysmorphia (and those with mental illnesses more generally) under the bus. I have participated in what amounts to distancing myself from those with mental illness and saying, “Hey, hey, hey, I’m not one of those people.”

And, it’s true, I am not a person who has to deal with a mental illness, such as body dysmorphia, but that is exactly why I have to be very careful how I choose to address the mental illness aspects of the difference. Let’s return to that phrase I said was important, “have a distorted view of how they look” to explore this difference. I don’t have personal experience with actually living with body dysmorphia, so my condensed description here comes from various descriptions and case studies I have read. I will try my best to be sensitive while still representing an accurate picture to be found in the sources.

Those who suffer from body dysmorphia have a disconnection between the reality they are perceiving and how that perception is recognised in their brains. They look in an ordinary mirror, but for them, the result is something like we might imagine a funhouse mirror to look. There is an inability to recognise the body for what it is. Features seem distorted, and flaws (real or imagined) are perceived as much much worse than they are (if they even exist, and if they’re even flaws in the first place). No one is really sure why this misperception develops. According to the NHS, there might be a genetic link, but it also seems likely related to bullying in childhood. My own personal conjecture is that beauty standards have a lot to do with it. NHS also notes that body dysmorphia affects both women and men in roughly equal amounts, which I think is extremely important to think about.

Body dysmorphia, even if it has a genetic link, does not appear to have a specific medical treatment, although counseling and antidepressant medications are recommended. Surgery is NOT a treatment. Recall that there is a disconnect between the reality being perceived and how the brain is interpreting those perceptions. That disconnect is in the processing of perceptions, not in the reality. Therefore, while some individuals with body dysmorphia do seek out surgery to correct the flaws, they are typically unsatisfied with the results. No matter what is done to the body, it is the perception process which has the issue. According to many of the descriptions and texts I have read, it is very dangerous to allow someone with body dysmorphia to have access to surgery because it is not treating the problem and may ultimately do harm.

So how is this disconnect different from the disconnect between the assignment of gender at birth and the gender identity of a person with gender dysphoria? It is substantially different in that one of the strongest aspects of gender dysphoria for many (but not all!) individuals who have those feelings is an acute awareness of what their physical features actually are and why those features do not match up with the gender presentation expected of the gender with which they identify.

Let’s put aside the possibly derailing argument of “there is no wrong way to look like a man and no wrong way to look like a woman” which we often try to advocate in both feminist theory and in trans-queer theory (especially when it comes to removing ourselves from the binary framework), because it isn’t helpful here. We need to recognise that gender presentation standards do exist and they are strictly and harshly (sometimes violently) enforced. It’s unfair to those with gender dysphoria, especially trans children who we should not expect to be engaged in gender deconstructive discourse at our level, to make this argument in response to claims of gender discomfort. We live in a world with two very strongly enforced boxes, and a great number of us fit into one of those two boxes at least tolerably well, even if the box we are in is not the one we were originally assigned. This is definitely something we need to deconstruct, but for the purposes of this discussion, we need to discuss what is not what we would like to be or we aren’t being helpful in the immediate.

The reason why body dysmorphia and gender dysphoria seem to be so often conflated is because of the physical aspects of gender dysphoria. These aspects, the dysphoria as mentioned above (recognising physical traits which are gendered and how their appearances do not match up with the expectation of the gender presentation associated with one’s actual gender identity), are really sex dysphoria, and not every person with gender dysphoria has the same type of sex and gender incongruence as others. In fact, some individuals have no real or at least no overwhelming sex dysphoria. Yet they still have gender dysphoria because they are dysphoric over other aspects of gender expression, presentation, and identity. Then there are individuals like myself who have pretty persistent, consistent, and insistent sex dysphoria tied up in our overall gender dysphoria, but remain well-adjusted because of a combination of personal coping mechanisms, supportive friends and family, and access to the required medical care without too many hoops.

Using myself, again, as an example (because it is the experience to which I have the most and closest access), I definitely have sex dysphoria. Let me make it quite clear: I have had persistent, consistent, and insistent so-called “mapping” issues between my body and my self-conceptualisation for as long as I can remember. What makes these issues different from body dysmorphia is that I can recognise those aspects of my “male” anatomy which do not match up with my “mapping” as actually existing and as “mine” in an objective sense. I can accurately describe my “male” genitalia’s physicality. If I was a cisgender man, I imagine, I’d be pretty darn happy with it, but I am not a cisgender man. I am not disconnected from it, and it is definitely not the case that it functions like some kind of reverse-phantom limb, and fundamentally I do not want the entirety of its physicality gone. However, in its current configuration, it is frankly the source of a great deal of discomfort, especially now as I am professionally, socially, and almost entirely legally transitioned.

And let me tell you, does it ever get in the bloody way. All the time. It’s incredibly annoying. Not so much in a distressing way, but in “dammit, I don’t have time for this” kind of way. This wasn’t as big of a deal for me when I was a child. I still often thought to myself, “well this makes no sense, this should not look like that” and “why is this even here?” And I certainly didn’t want it around. As a kid, truth be told, the issue was largely moot. It’s not like I was in situations, typically, where my anatomy was physically on display. That would begin to change once I hit adolescence.

Not only was I now in the situation where locker rooms were an issue, but I also had a very good understanding of how hormones cause puberty. I knew my genitalia was the cause of what masculine development was occurring, and I also knew it was the reason I wouldn’t be developing like the cisgender girls around me. While I was too rational to “blame” my anatomy (personification is stupid, it’s not like my anatomy did it with some kind of sentient purpose), that didn’t keep me from wishing the source of testosterone would just disappear.

I think it was around the fifth or sixth grade when I first started having terribly over simplistic and not very accurate “Well, why can’t it just be removed?” type thoughts, which invariably led to considerations of how I might accomplish it. Thoughts I dismissed not because the idea didn’t appeal to me at some level, but because I knew it was unreasonable, would create more problems, and would ultimately hurt a lot. Remember, even then I had the knowledge that my genitalia was indeed objectively part of me, and while I didn’t want it, I also didn’t feel disconnected from it.

Indeed, I had enough sense (or maybe just fear) to realise that I was already battling the idea that I was mentally disturbed because of my behavioral issues, and that such an extreme action would “confirm” that I was not well-adjusted. There were nights when I cried myself to sleep unable to figure out a solution to my mounting problems. I was a very, very unhappy child. However, the very fact I could consider the issue fairly rationally and come to a safe and responsible conclusion to do nothing hasty strongly indicates a firm grasp on reality.

This can’t be a form of body dysmorphia, because the issue is not a processing error between the reality of physicality and how that physicality is understood internally by the mind. There is no failure to see the body as it is. The issue is something else. And that issue is largely tied, in my view, to the intertwined nature of sex and gender. Although it has been posited by some that the so-called “elimination” of gender will lead to a lack of sex dysphoria since sex will no longer be tied to the personal aspect of identity we now recognise as gender, I am not so sure. This is especially true as we discover more and more about the likelihood of non-dimorphic traits amongst those who identify as transgender.

In my own case, my issues with processing testosterone, referred to as androgen receptivity issues, and empirically observable physical “mapping” issues in how sensations are passed from body to mind indicates that my own issues with physicality are not to be found in my mind—but rather in the body. Since we live in a world where gender does exist and we categorise physicality and physical sensations we feel and observe in terms of gender, it is impossible to say how individuals with these clearly provable physical differences would feel in a world without gender. However, if they are, indeed, empirical, observable facts, then those differences would still exist in such a hypothetical world. Perhaps then, even if gender dysphoria were to not exist, some concept roughly equivalent to sex dysphoria still would. It’s a neat thought experiment to consider how such individuals would function in a genderless society, but ultimately it does not help us here in our own.

With the fact that the sex dysphoria aspects of gender dysphoria are a physical reality, which in some cases, can actually be observed and recorded (as in the case of my own), this pretty much contradicts the notion that being transgender is in the mind only. And if acute awareness of physicality is an aspect of gender dysphoria which is precisely opposite of the defining aspect of body dysmorphia, it should follow that physical changes as the result of medical intervention would generally lead to solving feelings of dysphoria (unlike surgery for those with body dysmorphia which actually can cause more harm). And indeed, that has repeatedly been shown to be the case in study, after study, after study, after study, even with the potential for complications and need for future medical intervention post-operation for both trans women and trans men.

Participants, all of whom were at least 1-year postoperative, completed a written questionnaire concerning their experiences and attitudes. Participants reported overwhelmingly that they were happy with their SRS results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret.

Treating the physicality aspect of binary gender dysphoria is, relatively speaking, a very clear medical process which has now been conducted (with obvious progress in knowledge and technique) for decades. It’s well understood and, most importantly for the purposes of our discussion here, comes with an end. The process stops once the physicality matches both the internal and social conceptualisations of self. Such medical processes are not only impossible with body dysmorphia, they would be dangerous if applied to those suffering from it.

When gender dysphoria and body dysmorphia are conflated, it causes harm to be done in the search of wider understanding of both of these issues. There is no such thing as gender dysmorphia. If there was, it would probably refer to a type of body dysmorphia where one believes she or he has aspects associated with the opposite sex and is distressed by this fact. It would pretty much be the opposite of gender dysphoria entirely. To confuse the two, and to combine them into some sort of catchall mental issue, is to do a disservice to both transgender individuals and those who suffer from body dysmorphia. Both groups need support and understanding from wider society, but how that support and understanding is conceptualised and presented will be as different as the issues they seek to address. The ability for support and understanding to be applied is far less effective when these differences are not understood.

Please stop conflating the two. It does neither of our groups any good and ultimately only causes us harm.

Image via Shutterstock.

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