The Difference Between Dysphoria and Negative Body Image

Most people understand body dysphoria as a dissonance between sense of self and body. But what does that mean?

Is dysphoria the same as feeling uncomfortable after gaining weight? Is it the same as hating your big honking nose? Or is there a fundamental difference between dysphoria and other feelings of bodily discomfort? I think about this quite often. Am I dysphoric about my hips, or do I just feel inadequate in a world where femaleness is defined as possessing childbearing hips? Am I dysphoric about my facial hair, or am I self-conscious because the rest of the world judges hairy women? When is discomfort over my body a result of testosterone poisoning, and when is it a desire to be more attractive? Is it possible to tell the two apart?

This is not a philosophical question. Insurance companies categorize trans medical care as “cosmetic” and use this as a justification to deny coverage of trans-specific procedures. Psychologists write off body dysphoria as a delusional manifestation of body dysmorphic disorder. Friends and family dismiss the extreme pain caused by dysphoria and tell us to “just accept who we are”.

The difference between dysphoria and negative self-image is important for us as people, as well. The mystique surrounding dysphoria holds us back from living fuller, happier lives. Dysphoria is a vaguely-defined and poorly understood phenomenon. Most descriptions of dysphoria are intuitive, personal, and vague. How can we understand ourselves without the language to describe specifics? How can we develop useful coping strategies with such a limited understanding of the inner workings of dysphoria? How can we explain to the cisgender population–who often have the final say in whether or not we get to live happy, full lives–what dysphoria is and is not, unless we dig deeper?

One trans medical treatment that’s misunderstood is facial feminization surgery (FFS for short). Some people think the desire for FFS is rooted in the pathology of mainstream beauty standards. They think trans women get FFS to look like supermodels. These people are completely wrong.

When Illusion is Reality

I’m going to be blunt: I am not attractive. Even under ideal conditions, my face isn’t pretty by conventional standards. It won’t win any beauty contests. It won’t appear on any magazine covers. Although estrogen halted the worst of my acne, I still have complexion problems. My skin is littered with deep acne scars. My pores are huge, and my skin color is splotchy. I have a large nose and small eyes. I’m not throwing a pity party; these are just the facts. Mainstream beauty standards are a scam as far as I’m concerned, but I can’t pretend to be immune to them, either.

My face is my primary source of discomfort. I can’t avoid it; I interact with my face every day when getting ready in the morning. And every day, my face looks different depending on how I feel. On bad days, I am overwhelmed with memories of my appearance pre-transition. My face looks hypermasculine to me, even though I regularly get read as a cis woman. This is clearly a problem with self-image. It doesn’t correlate to reality. It’s an emotional distortion. On good days, my face looks dramatically different. I stop seeing “the old boy” in the mirror, replaced with a face that feels right. It actually looks a lot like my face before I went through puberty the wrong way.

However, my face only feels right when I look at it straight on, in even lighting. Viewed directly from the front, without any shadows to reveal depth, my face registers as my own. It feels right. If I slowly turn my head, the dimensions of my face gradually stretch and become less and less recognizable. My face morphs into someone else’s. The effect is similar to perpsective-based optical illusions where a model or image appears to have a familiar form until you change your viewing angle:

The feeling invoked when I look in the mirror is the same as when I view these illusions. They are confusing, disorienting, and unsettling. To me, these emotions are the defining characteristic of body dysphoria. Beauty has nothing to do with it: When Ngui’s chair breaks apart into several pieces, it no longer makes sense as an object. Parts that appear connected are, in reality, separate pieces. Half of the chair’s seat is actually a painting on the floor. The brain creates a spatial model of the chair, and then that model is violently torn to shreds when exposed to physical reality. The viewer is upset: this was supposed to be a chair, and this is not what a chair is supposed to be at all! Varini’s painting appears distorted when the viewer steps away from the sweet spot, not because of any inherent quality to the painting, but because the brain has created an expectation of how it should appear. The viewer is disoriented when stepping away, as if space itself has warped. Sugihara’s paper sculptures are mind-bending not because they appear to defy the laws of physics, but because the brain expects different behavior from the objects it sees. The ball should roll down the slope, not up it! The result is jarring.

(The official, full video of Kokichi Sugihara’s illusions can be found here.)

Dysphoria causes the same dizzying confusion, because the brain expects the body to take up space differently. These hips should be wider. These shoulders should be narrower than the hips. When a situation calls attention to these inconsistencies, it’s like Ngui’s chair breaking apart, or Varini’s painting stretching out into space. The brain also expects the body to behave differently. To trans women who are dysphoric about their genitalia, an erection is as confusing as a ball rolling up a slope. It doesn’t make sense.

I use special techniques to alleviate these upsetting feelings. I wear black cardigans to minimize my shoulders. I layer shirts with long torsos over full-rise jeans, widening the appearance of my hips. When I masturbate, I usually cover myself in blankets and utilize guided visualization and deft hand maneuvers to make things feel right. I dodge mirrors, except for when I encounter those ideal viewing conditions and my real face shines through–then I stare at my reflection and burn the image into my mind. Using all these tricks and more, I can temporarily put Ngui’s chair back into a comprehensible form. I can line up Varini’s painting until it looks right again. I can make the ball roll down the slope. But they are all temporary solutions that require constant maintenance.

Trans medical procedures such as FFS offer a permanent, tangible solution to dysphoria. Instead of the illusion of a chair, you get an actual chair! The chair may not be as pretty as you had hoped, but damn it, at least it’s actually a chair! You can finally give your sore legs a rest without falling on your ass! And it’s a chair no matter what angle you view it from. Instead of a painting that disappears when you step away from it, you get a painting that looks the same from every angle. With SRS, the ball rolls down the slope like it’s supposed to. Everything works as expected, without thick blankets and mind tricks.

Surface Matters

Having described the essence of dysphoria, the question remains: What is the defining characteristic of an actual negative body image? We are just as prone to negative self-esteem as cisgender people–potentially moreso, as we are held to higher standards by cisgender people and start at a disadvantage.

Let’s return to Ngui’s chair. This time the chair’s paint is peeling off. One of its legs is cracked down the middle. The seat was severely water-damaged and is now rotting away. Regardless of all these defects, if the chair is just an illusion it will break apart when you look at it from the wrong angle. And if it’s a real chair, you can still sit down on it. The experience might be uncomfortable, but you can still rest your legs. Maybe you fantasize about sitting in a prettier chair, but at least you don’t have to gaze longingly at it from afar while using tricks to make yourself believe it’s really a chair.

Your slope doesn’t need fancy embellishments to make the ball roll downward like it’s supposed to. No amount of pretty trimmings will change the laws of physics. Regardless of how pretty your slope is, if the ball rolls against gravity it’s going to be disturbing.

My face would be a lot more attractive if I had perfectly smooth skin. But I would still need that perfect light and viewing angle to avoid dysphoria when looking at myself in the mirror. My face would look more feminine if I had a smaller philtrum (the space between the nose and upper lip). But it would still trigger dysphoria when viewed from the side. Conversely, if my brow line was reduced in prominence, and my nose didn’t stick out so far, my face would look the same from the side as it does in my ideal conditions.

All it would take to “fix” my face is to flatten it out a bit along one axis. I would look the same from the front, but that image would stop falling apart when I turn my head. The chair would stay a chair. After more than 18 years spent on my feet while tormented by the mirage of a chair, I’d be happy to sit in any old chair. I just want the real thing.