Dysphoria is a pervasive feeling of discomfort, discontent, or dissatisfaction with life. “Gender dysphoria” is a term that has been around for a couple of decades, specifying gender as the cause for the feeling of dysphoria. Some of the ways people describe the experience include: “I just don’t feel right in a female (or male) body,”  “It’s just not right when I look in the mirror,” “I’m living a facade.” I heard a wonderful line in a song once that captures the experience well: “I am a tourist in my own life.”

For those compelled to transition physically, gender dysphoria is alleviated once they are perceived as their intended gender, and their brains are experiencing the right hormone balance. There are people who will often or always be seen as trans, who don’t feel they will ever be invisible as men or women on the other side of transition. However, if they reach a point of not caring what others think, they might feel, “Sure, I’d love to be seen as a woman (or man), but that’s not my reality. However, it’s so much better that people don’t see me as a man any more (or woman), that’s the main thing, and I love it!”

Often overlooked is the fact that body dysphoria can become more acute once the gender dysphoria is addressed. Hormones and living a new gender role can bring the brain/social role into alignment. But that can make body dysphoria stand out all the more as a prominent issue. Once the other issues have been addressed, this is the one that is left.

For most people, hormones are fairly easy to obtain, and can be built into the monthly budget. Surgery, on the other hand, is out of reach for many. This leaves many still saying “It’s just not right when I look in the mirror.” The difference is, now they are looking in the mirror with no clothes on, and that’s not something anyone else in their lives will see, if they don’t want them to. (For some in this position, their greatest fear is being taken to an emergency room unconscious and helpless) The social presentation of gender is fine – but the body issue still isn’t. Even for those who can afford surgery, “affordability” usually means saving for a number of years, and then ordering one’s life to have sufficient time away from work or school to heal from the procedure(s).

Common issues I’ve observed among clients in this position are:

• Depression and/or social anxiety. One client, seen as male in all situations, found his anxiety increasing to intolerable levels when he got a new job where no one knew he had once transitioned. He feared one of his male co-workers would thump him on the chest in a brotherly fashion, and would then realize that he hadn’t had chest surgery;
• Despair, sometimes to suicidal levels. One client said, “I work minimum wage. How can I ever save the money for chest reconstruction surgery? But I feel like I’m stuck in my transition, can’t ever date or consider getting into a relationship. Emotionally that’s what I’m ready for, but I can’t get past this chest.” This particular client had had relationships prior to transition, but his chest had been “off limits” to his previous partners. The difference now was his invisibility – he knew any woman he would date would relate to him as a man, and he could not tolerate the thought of them finding out about this one remnant of what he considered “female.” It felt like regression to have to tell any potential girlfriend that he lived the first 24 years of his life female. Now, at 30, he said, “Is this what the rest of my life is going to be?”
• Isolation and loneliness. Quite a few of my clients have resigned themselves to living their lives alone, certain they will never be accepted. Their bodies are “between male and female,” as one client described it. This becomes a self-fulfilling prophecy; they certainly will remain single if they never allow others sufficiently close to consider relationship.

It’s not easy to revise one’s perception of reality. The clients who have done so have had epiphanies such as:

• Ed remarked, “Of course I wish I’d been born with a penis! I’m a guy, always have been, always knew that. But I wasn’t born with one. Okay, so now I see myself as a different kind of man. What helped me was when I read an article about some of the history of transition and realized that phalloplasty was developed to help cisgender male soldiers who lost their dicks in wartime. Wow — there are cisgender men who don’t have dicks. And I thought, ‘How much worse to have really been born with one, and then to lose it…’ Actually made me feel lucky.”
• Eileen, a 55 year old transwoman, had been feeling extremely lonely, her wife of 30 years having left her over the transition. Eileen was told by her doctors her health was such that lower surgery wasn’t a good option for her, leaving her feeling she would never be accepted by a partner. Then Eileen went to a support group meeting and overheard another transwoman, about her age, saying, “My wife doesn’t want to know I’m here, so we never talk about where I go on these evenings.” Eileen was struck forcibly by what a lonely experience that would be, and remarked in our next session, “It made me realize I’d much rather be alone than lonely in a relationship.” She worked instead on developing and deepening friendships, now available to her in a much different way than when she’d been living male. Ironically, one of these friendships blossomed into a romantic relationship over time. Eileen told me, “I wasn’t looking for another love relationship, and ironically, I think that meant I was actually ready for one! I didn’t need it, in that dependent, lonely kind of way.”

What do these very different stories have in common? A feeling of being enough. Both Ed and Eileen had come to a place of self-acceptance by internalizing the belief, “I am enough.” Yes, at times each still wished they’d been born cisgender, or that they could undergo a perfect surgery. But each had also realized the depth of personal growth they’d experienced through transition was a gift they could not have acquired any other way. Ed put it well: “I used to want a partner who could accept me in spite of my being trans. Now I look at it differently — I want a partner who loves me for who I am, which includes being trans.”