When Alex* was in high school, they became obsessed with their appearance - which the adults around them assumed was a normal, developmentally appropriate (if somewhat annoying) stage all teenagers go through. What teen doesn't spend hours in front of the mirror or change their outfits six times before meeting friends?
But when Alex graduated and went to college, this focus on appearance began to take up more and more of their time, and their thoughts became quite negative. They recall a weekend when they sat in their dorm room taking close-up selfies of their face and then looking closely at the photos, noticing what they called "flaws" - their eyes seemed to be misaligned, their nose was crooked, their cheekbones weren't as prominent as what they would have deemed "perfect".
"My roommate was away for the weekend and I literally sat on my bed and took selfies and then zoomed in on them for hours on end. I had a lighted makeup mirror and kept looking back and forth between the pics and my face in the mirror, thinking about how ugly my face was, how I thought it looked deformed," Alex recalls. "I didn't even notice the time passing until suddenly it had gone dark outside. I had been there for about 12 hours and hadn't eaten or gone out at all. Just 12 hours staring at my face."
Alex is nonbinary and uses they/them pronouns, and says they've always had ambivalent feelings about their body. "I was assigned female at birth (AFAB) but I never felt particularly feminine. When I hit puberty and developed breasts, I was pretty weirded out because it didn't feel right to have breasts - I didn't feel like a girl inside. But I also didn't want to be a guy so that was confusing. When I was about 14, I settled on nonbinary as my identity."
Alex's focus on their face started in high school when they were experimenting with makeup. "I never felt attractive and wore a lot of heavy, dramatic makeup which totally disguised my facial features," they say. "When I went to college I was spending more and more time on my makeup every day, wearing more and more makeup, and it actually made my skin break out really badly."
When Alex took a break from makeup to try to heal their skin, they felt worse, not better, about their appearance. As their skin cleared up, they started fixating on their face structure. "I thought my eyes were 'wonky' and my lips were too big, stuff like that. Every time I looked in the mirror I just thought that I was so ugly. I didn't want to go out in public without makeup because I honestly thought I looked like Quasimodo and people would notice."
After that "lost weekend", as Alex describes it, where they spent a whole day just staring at their face and cataloguing its perceived flaws, they decided to go talk to one of the campus counselors. Their roommate, who had noticed Alex was always very negative about their appearance, was supportive and encouraging.
"I didn't know what was wrong with me but I knew I didn't feel good about myself," Alex says. "When I told my roommate I was going to go see a counselor, she said she had been really worried about me because she'd noticed how negative I was about myself. That woke me up a bit - that my roommate had seen something was wrong but that it wasn't my appearance, it was my mental health that concerned her."
A further wake-up call happened for Alex when the campus counselor suggested she might be suffering from body dysmorphia, and referred Alex to a therapist specializing in the disorder. "I didn't know there was a name for what I was dealing with," says Alex.
Body dysmorphia, also called body dysmorphic disorder (BDD), is a recognized mental health condition characterized by an obsessive focus on perceived flaws in your appearance. These "flaws" are often minor or even imagined, but the person with BDD can't stop thinking about the flaws, and it causes them major distress. Body dysmorphia is not uncommon for trans or nonbinary people like Alex, it can be linked to their discomfort with a body that, in Alex's words, "feels wrong".
BDD is thought to affect between 0.7% and 2.4% of the population - and it affects everyone, including men, women, trans, nonbinary, and agender people. But it is likely underdiagnosed, as sufferers become skilled at hiding the symptoms from others (who might just label them "vain" without understanding).
People who have BDD might engage in compulsive behaviors like excessive grooming, the need to constantly "check" the flaw or flaws they perceive they see, seeking reassurance from others (but not believing them), and avoiding social situations or friends because they are concerned others will judge their appearance. It can be very isolating and take up a lot of brain space and disrupting their everyday lives, leading to anxiety, depression, and a diminished sense of self-worth. For queer individuals, societal norms and beauty standards can exacerbate these feelings.
It can be hard for someone with BDD to recognize the problem, as they believe that others are not telling them the truth, or are "being kind" to overlook the flaws they feel are so obvious. Some people with BDD seek plastic surgery, medical treatment, go on extreme diets, or exercise compulsively to try to "correct" what they are concerned about.
It took Alex a few months to come to terms with having a mental health condition, they say. "I was lucky to be able to see a therapist who understood what I was dealing with and who was identity-affirming. And I was lucky to have good health insurance through my parents, that would cover my appointments. I think there are a lot of people out there who just suffer in silence, especially in the queer community."
There is no one-size-fits-all treatment, as everyone's experience is unique, but generally speaking, dealing with body dysmorphia requires a multifaceted approach that combines self-compassion, professional help, and community support.
First, work on practicing self-compassion. Acknowledge that your feelings are valid, and allow yourself to feel them without judgment. Consider journaling or engaging in mindfulness practices to help ground yourself in the present moment. Affirmations can also be powerful; remind yourself of your worth beyond physical appearance. Above all, try to treat yourself with kindness. If a friend came to you saying they feel how you feel, you would treat them with kindness - do the same for yourself.
"My roommate, who became my best friend, was such an integral part of my journey," Alex says. "She encouraged me to go to therapy, and it made a huge difference to know she was there for me."
It's critical to seek professional help, preferably from an experienced and registered mental health professional. Therapy, particularly cognitive-behavioral therapy (CBT), has proven effective for BDD as it can help people recognize faulty thought patterns. A mental health professional can help you identify and challenge negative thought patterns, providing tools to reframe your perceptions of your body. If you’re part of the queer community, finding a therapist who understands and respects your identity can create a safe space for healing. Antidepressants, when thoughtfully prescribed and when used in conjunction with therapy, can also be helpful.
Community support can also make a positive difference to sufferers of body dysmorphia. Surround yourself with people who love and care for you, and who affirm your identity. Online communities can also offer a platform for connection with others who share similar struggles - and can help to reduce feelings of isolation and misunderstanding.
Another helpful idea is to engage in activities that promote physical and mental wellbeing. Seek out opportunities to do things that are good for your brain and body. Exercise can boost your mood and self-esteem, while yoga, meditation, and mindfulness can help you to foster a healthier relationship with your body. Nourishing your body with balanced meals and ensuring adequate sleep can also support your mental health.
Unfortunately, the lengths people can go to in order to try to "normalize" the physical flaws they perceive generally do not work to alleviate the symptoms of BDD. Cosmetic surgery, extreme dieting (eating disorders have been linked to BDD), and other measures don't have the desired effect as for people with BDD, their opinion of their appearance isn't based on reality.
Social media can also exacerbate feelings of inadequacy because it presents unrealistic, highly filtered standards of beauty. Consider curating your social feed to follow body-positive accounts and communities that celebrate diverse identities and appearances. Taking breaks from social media can also provide a necessary mental reset. It's okay to detox from social media - it can be toxic to your mental health, so prioritize what brings you peace and positivity.
Ultimately, Alex needed to take a year off of college to work on their mental health, and says it was the best decision for their situation. "The college environment wasn't conducive to my mental health - lots of partying, drinking, etc - and I just needed some peace and space. I ended up back at home with my parents for a year, going to therapy and figuring things out."
Alex returned to college feeling more grounded and with tools to help them move forward positively. But they caution that they don't think they will ever be "cured" of body dysmorphia. "The underlying feelings are hard to root out, but I have techniques and strategies now to deal with what I'm feeling, and I have a better understanding of what to do if I get triggered into a flare-up of those feelings," Alex says. "I still go to therapy, although it is less often than before, and I'm okay with knowing I might need help with this for the rest of my life.
"I would much rather see a therapist and take antidepressants for my whole life than go back to feeling as awful as I used to feel about my face and body."
* Name has been changed to protect the privacy of the interviewee.
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