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Body Dysmorphic Disorder and FFS



FFS and Body Dysmorphic Disorder


It is easy to understand why any woman, whether TS or not, would be upset about having a masculine face. Not only can it cause all kinds of social problems but it is psychologically very distressing for a woman to look into a mirror and see a male face looking back at her. So having FFS to try to remove or reduce those masculinities is reasonable and understandable.

Even without a masculinity problem, we can all be a little down on our faces and ourselves from time to time - this is quite normal of course but I regularly come across women, both TS and non-TS, who are convinced that their faces are far more masculine or far more unattractive than they actually are. This kind of unrealistically negative view of your body or parts of it can often be down to a very common psychological problem called “Body Dysmorphic Disorder” (BDD). It is a problem that I suspect transsexual women are particularly prone to - spending so many years trapped in the wrong body and behind the wrong face can easily lead you into the habit of looking at yourself with disgust. This is all made worse by the fact that the societies we live in often see TS women as laughable freaks.

BDD is nothing to be ashamed of - as I said, it is very common and it is very easy to fall into. It is thought to be a symptom of underlying anxieties about yourself and is one of the ways that these anxieties can express themselves. So if you have negative opinions about yourself, for example: if you think you are inferior or worthless etc. this can cause you to focus on your physical appearance in a very critical way - so much so that you start to see big physical problems when they aren't really there or at worst are very slight.

It might be hard to believe that you could fall for this but the human brain is very vulnerable to this kind of thing and the way we see the world is always subjective and distorted. A trivial example might be when you look at an old photograph of yourself and you can't believe how you ever thought that outfit or that hairstyle looked good on you. But of course you did at the time - you looked in the mirror and thought “yes, that looks good!”

Let me give you an imaginary example of normal concerns a person might have about their appearance compared to potential BDD behaviour: Look at Jennifer Aniston - she has a bit of a square chin.


picture courtesy gdcgraphics

If she said to me that she didn't like it, that she thought it was masculine and that she was considering having surgery to make it more rounded, that would be fairly reasonable. I might attempt to talk her out of it - she's a beautiful woman just as she is and although it is technically a masculine chin, it doesn't in any way make her look manly. There are also risks involved with chin surgery that would need to be considered. If, on the other hand, she told me that her chin was repulsive, that she couldn't look in the mirror because she is so ugly and that she will do anything to get rid of it, that would clearly suggest that there was probably a psychological problem there like BDD.

Having surgical alterations made to your body is, of course, a matter of personal choice and I have no objection myself to people choosing to have even quite extreme things done like facial tattoos or having little horns put under their scalp etc. but choosing to have a surgical alteration with a clear mind, as a matter of personal choice and self-expression is not the same as desperately seeking surgery to correct problems that are not really there or are at least greatly exaggerated in your mind.

The problem is that you cannot fix BDD with surgery and trying to do so can be very dangerous because the patient may very likely still feel awful afterwards even if she looks great. This is because the problem is not so much with the way the patient looks, as with the way she sees herself and to find yourself in this situation after surgery, with your money gone and with no apparent options left is devastating - sometimes to the point of suicide. Surgery may be an option at some point to fix any actual problems that are there but the BDD must be fixed first.

Something that concerns me greatly is that many surgeons do not pay enough attention to BDD. Some may not even be aware of it. Consequently, they sometimes recommend surgery inappropriately and at great risk to the patient's mental health. I have seen this many times and have had to try very hard at times to try to protect a patient from her surgeon.

Fortunately, you can fix or greatly improve BDD with a type of therapy called “Cognitive Behavioural Therapy” (CBT). CBT is being used by more and more psychiatrists around the world to treat a wide range of psychological disorders like phobias, depression, anger, anxiety and panic attacks. There is nothing mystical or technical about it, it is a practical and common sense approach to identifying where your thinking patterns are going wrong and correcting them.

Let me give you an example: a common thinking error, and one that I suspect TS women are particularly prone to is called “mind reading”. This, of course, is where you think you know what other people are thinking. So, for example: someone looks back at you in a shop and you immediately think “Damn, I've been read!” when of course there could be many reasons why they looked back at you - they might have thought you were attractive or you might have reminded them of their aunt; they might even have been looking past you at the shelves because they couldn't find the product they were after after. But you immediately assumed you'd been read and consequently felt upset. If you are prone to another thinking error called “all-or-nothing thinking” then you might immediately move on to “Oh what's the point, I'm never going to pass and there's no point in wasting my time on this hopeless transition any more...”

The object of CBT is to help you spot which particular thinking errors you are prone to and give you strategies to correct them. For example, with mind reading you are encouraged to think of the possible alternative explanations like the ones I gave above. You are also encouraged to remember that you are actually guessing what the person was thinking and to consider that your guesses might be wrong. One of the strategies for all-or-nothing thinking is to consider that there is a middle ground, for example, if you were read, does that really mean that it's all pointless? Most of us get read occasionally and still seem to get along fine. It's not nice when it happens but remember: some non-transsexual women get mistaken for men occasionally too. You can learn to take it and get over it. It's like tripping up in public. It's very embarrassing and it can be painful but you don't stop going out - you just pay more attention to where you're putting your feet!

Medication is sometimes prescribed for people with BDD to accompany CBT. The drugs are called “selective serotonin reuptake inhibitors” or SSRI's for short. Prozac is a well known example.


Typical symptoms of BDD:


Obsessing over a physical flaw.

Avoiding mirrors or continuously checking yourself in them.

Positioning yourself so that people can't see the flaws you are concerned about.

Feeling that you look like a man despite everyone or almost everyone taking you for female.

Hating your face or body.

Avoiding people who are attractive.

Avoiding social situations because of the way you look.

Describing yourself as “repulsive” or “hideous”.

Seeking constant reassurance from other people that you look attractive or feminine.

Self-harming or attempting DIY surgery on the problem area.


If you have BDD or think you might have it, or if someone like me suggests you might have it, then it is essential to try to resolve that before you have any surgery even if it is just to prove that you don't have it. There are 2 ways to get Cognitive Behavioural Therapy. One is to get it from a CBT therapist, the other is to get it from a book. As CBT is very logical and based on common sense, many people can fix problems themselves with books (bibliotherapy) and of course that's a lot cheaper than going to a therapist. Some people are not suited to the book approach and go straight to a therapist, others combine the 2 or seek a therapist after trying books first.

A book I recommend to get you started with CBT is:

Cognitive Behavioural Therapy for Dummies

By Rob Willson and Rhena Branch:

Let me make it clear that I am not in any way associated with the writers or publishers of this book. I recommend it because it helped me deal with my own BDD and with problems I have had with depression and anxiety. I found it extremely helpful and got on top of those problems for the first time in years. It would also give you a very useful set of mental tools for dealing with many of the big traumas of transition.



Here is a very useful website that has video interviews with a therapist and a sufferer of BDD.

You can read the Wikipedia article on BDD here. It's a little dry but it gives some detailed information and some useful links.