Working with Body Image Issues in Transgender People

Hugging self: hands wrapped around bare legsI decided to dedicate myself to investigating and writing about the experience of body in transgender people. Though I am by no means an “expert” in working with this population, I have learned significantly from people I have worked with who identified themselves as transgender. I set out to organize my observations and insights by grounding them in current research, to offer something of use to the reader that is legitimized by work in the field. It struck me that in looking at body-appearance satisfaction we could learn a lot from people who experience being born with, and living with, a body that they experience as opposite of what they were suppose to have.

What is the nature of the relationship to the body for transgender people? How do they value their body? How do they take care of it, take pleasure in it? How do they deal with other people’s perceptions versus what they see or what they wish they could see? Does that change if they are able to change their body to look like what they believe they were supposed to have? What I was to discover was a dearth of research and a complete lack of theory or even sufficient conversation on the topic. There was certainly almost nothing scientific or academic of any use to working with clients. So here are my truncated thoughts combined with what I learned in my search for information on a very complicated subject.

For those new to this area, know that for transgender people, the desired body isn’t a thought, or a feeling, or even a drive. History has shown that the experience is relatively unchangeable. I would describe it as an experience of persistent identity messages incongruent with the physical body. There is a “hardwired” nature to this lived experience, though science hasn’t found the neural connections yet. Despite abusive efforts to create aversion in people who feel they are in the wrong body, to force them to stop thinking of it and stop expressing it (society can’t handle ambiguity or non-conformity, apparently), transgender people don’t stop being transgender.

For most documented cases, it has proven to be a life-long struggle between the inner sense of self and the physical, external self. It has also, for most, been a struggle between expressing the true self and repressing it in order to earn or keep acceptance and belonging in relationships and in society in general. The extent that people (often rightfully) fear societal reactions to their true identity is directly related to how much psychological distress they suffer.

Interestingly, to the transgender child, there is no incongruence or distress about the body until they are confronted with the gender that is socially assigned according to the worlds’ image of them. They are often shamed, ridiculed, and otherwise discouraged from expressing what they consider to be their true selves, from an early age. You don’t have to be a therapist to think about the impact of such conditions of worth on the development of self-esteem. Indeed, transgender people have the highest rate of suicide.

There is some published anecdotal evidence that children who are allowed to explore their gender-related interests and self-expressions without external pressure to conform are better adjusted. There is also some research that suggests that trans people who have the resources and support to transition—and who believe they will be able to “pass” as the desired, chosen gender—have better mental and physical health outcomes. Also, while trans people have been shown to be at greater risk for developing eating disorders due to body-image dissatisfaction, depressive symptoms, and low self-esteem—they have also been shown to have reduced risk of these problems after gender-confirmatory surgery.

How do we begin to support these people or even understand their struggle and offer them hope? What is our role as therapists or friends in supporting transgender people? We know that body image issues are a problem for women who feel the pressure to conform to societal ideals and this can result in negative self-perception and negative health outcomes. In clinical studies, trans people have been described as being obsessed with the aesthetics of outward appearance. It makes sense that a trans person, having to live with a body that looks nothing like what they want and one that is often in complete opposition to social ideals for the gender they feel they are, would have even worse self-perception and greater negative health outcomes. So how do we help?

I believe in the fundamental healing value of acceptance and understanding of human experience. In my role as a therapist, I must be a non-judgmental mirror for the people I work with. In asking “what” rather than “why” questions, like at the outset of this article—I can get closer to an understanding that can allow me to mirror a person’s inner view of themselves. In that way I can strengthen the sense of self and self-worth of a person. I work to emphasize the importance of the functions and joys of the body, not just its appearance.

I share the idea that self-esteem comes from dedication to loving self-care and encourage habits that lead to better relationship to the body. This can be life enhancing for a person who has had very little acceptance and hence suffers low self-worth. Indeed most trans people I have met tend to focus on the well-being of everyone other then themselves. However, to truly support trans people in healing their relationship to the body, I must also educate myself on their unique experiences and needs, whether they are in transition or not. I must also be political in joining the struggle for their rights, including educating others. I must be an advocate that supports their rights to dignity and well-being, if that involves gender-confirmatory surgery or other procedures or services. Hopefully this article is a drop in the bucket towards that monumental task.

© Copyright 2011 by Shirley Katz. All Rights Reserved. Permission to publish granted to

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Kathy

    April 21st, 2011 at 9:42 PM

    Body issues exist not only in transgenders but also in other people. I’m not talking about the “I’m fat” feeling that is widespread but about a boy feeling like he is more of a woman and is stuck in a man’s body…Such cases do occur and I have read about them. While this issue is obviously more prevalent in transgenders,it also gives a major plus.

    It gives us a precise idea about who are the people that need support programs in order to actually feel better about themselves, to prevent negative thoughts and to save lives from falling into the pit of suicide!

  • Tiffany

    April 23rd, 2011 at 6:54 AM

    Body image and dealing with what we look like to ourselves is something that everyone struggles with from time to time. It has to be even more difficult an issue for someone who also faces other circumstances like being transgendered. I agree with the authour that I believe in love and support for all, no matter which sex they choose to live their lives as or who they choose to enjoy a relationship with.

  • Frank

    April 29th, 2011 at 10:23 PM

    There was a story in the press this week about a transgender woman being beaten up in a McDonalds of all places in Maryland. Why can’t these animals leave transgendered folks alone? These folks aren’t harming anyone. I did read the assault charges may be upped to hate crime based on gender identity. Let’s hope so.

  • Penny Rayas

    April 30th, 2011 at 12:33 AM

    Thanks for the acticle Dr Katz. I have worked with transgenter youth. I believe the body issues are greater for them, especially if they don’t “Pass” as the gender they identify with. I had a trangendered woman client who was rejected by other women because she wore no make up or dresses. It was painfull and she was isolated. Transgenter people exist in all levels of spectum of how much they are willing to transition by taking hormone treatments. Many do to side affects of hormon therapy have to stop and end up with an ambigious look. They concider themselves the gender they transitioned to but may not look much like it. They may like the way they look and get negative feedbak from others. Yes we all need to be supportive and kind.

  • brianna

    April 30th, 2011 at 3:12 PM

    I can’t even imagine what it’s like to be transgender. I doubt it’s anything like me looking in the mirror and saying “I could use less fat”. I don’t know if I could handle that quite honestly. Kudos to all those transgendered people who do every day and keep on going.

  • Shawn

    April 30th, 2011 at 6:43 PM

    It sure isn’t like you thinking you could use less fat, brianna. People who are transgendered have body image problems they can’t reasonably do anything about at all. They have a problem with their entire body’s sex, not just a couple of extra pounds.

  • Cameron

    April 30th, 2011 at 7:35 PM

    I know two trans people. They do request that I refer to them as She (which I do), but that’s really the only way it affects me. Not sure if either of them plan to get the op however. Really it’s none of my business.

  • Jordy

    May 3rd, 2011 at 4:24 PM

    The amount of psychological hoops a transgender person jumps through is quite astounding. Even if you could get your entire body changed down to the chromosomal level, you could still have problems with your gender identity.

  • Caleb

    May 3rd, 2011 at 6:42 PM

    Gender identity in society is just one of the stresses of it like it says. If a child is transgendered, they simply do not care until society starts slapping gender expectations on them even though the only difference between the sexes is in how they contribute to giving life.

  • Spencer

    May 5th, 2011 at 7:27 PM

    @ I think that much of the self-esteem issues in society comes from that dominance BS people keep shoving on others. “Act like this, not like how you want to.” That kind of bullying tactic is a major issue even in the year 2011.

  • Shirley Katz, Ph.D., CCC

    May 31st, 2011 at 9:03 AM

    Great contributions, thoughtful and right-on. Thanks guys.

  • Nadia

    March 28th, 2012 at 6:26 PM

    As i sit here today after a constant atruggle a daily battle of what i c and what i hear on a daily basis,im all smiles.Im not much of a reader but a visualist.I paint pictures of what i hear.So this article and everyone that has put in thier 2cents …is ABSOLUTELY BEAUTIFUL to mr.The luv the compassion the “trying” to understand and the support, is exactly whats uplifted my spirits tonight.As i sit here and struggle w all my demons at the hilton dallas tx,i see how comfortable and relaxed everone around appears to be.I on the other hand am expressing to u all my soul.Being transgender is more u could EVER imagine.. MIND BODY and SOUL.
    Thanks again Dr.Katz wish EVERONE thought like you.

  • Justine Mara Andersen

    June 8th, 2012 at 6:39 PM

    As a transwoman I find that my self-esteem (not as a person, but I am talking here about body-image) can vary wildly not only from day to day, but moment to moment. Overall I am happier than I have ever been, and finally I love myself… and I smile almost ALL the time now that I have “become” who I wish to be. But, today, for example, I walked down Main Street to do a little shopping and I could not believe what was happening… I had five or six people cat-call, comment, honk, and proposition me in flattering and very kind and positive ways. And I knew I was being viewed as a sexy woman and not as an object of a very particular fetish… there just ain’t that many people into it that I would get so much positive response from people who dig transwomen. I was on cloud nine! I was not only passing, but was found attractive… obviously extremely attractive. Then, later that evening I reviewed a video of myself that was shot while I was doing a demo in class and I got site of my hair. Yes, the hormones have changed me in a positive way (yes, I am on hormone replacement therapy) but it has also made my hair frizzy and ridiculous looking (at least to my eyes when I saw the video) and I went into a negative spiral and started looking for articles on self-image issues among transgendered people. For me the issue is incredibly complicated and I experience wild highs and lows. I don’t have answers, just needs, wishes, and the desire to share. But the ONE thing I do KNOW… is THIS is who I am, and for the most part I am far better off.

    Justine Mara Andersen

  • Amanda

    June 30th, 2012 at 5:35 PM

    I consider myself transgendered though I have not transitioned. I really want to but keeping a job and survival keep me from moving forward.

    I am not very masculine looking and probably could pass as a girl as easily as a boy. I am 5’7″, have a voice that is slightly lower than the average female(I can’t really sing below an e3) and hips. I really didn’t have many body image problems until I was in my early twenties. I hated my privates and thought they were huge(they aren’t relatively). I also occasionally wanted breasts but otherwise I liked my body because I could ignore the other masculine traits and being an effeminate looking boy was a lot better than looking like one of the people on tv. I always saw a girl when I looked at my face and that made me happy.

    Then, I became ill and for some reason or other I ended up with some facial hair and a lot of my hair fell out which was horrid. My face also became a little more masculine and I started to not know the person I was looking at. I suddenly was looking at a face that was not quite masculine nor feminine and just felt really alien. That was very hard.

    I tried to transition when I noticed this with no means and a lot of desperation. It didn’t really go well and I ended up in mental hospitals. I felt like my parents were treating me like a caged animal.

    Today, I have had jobs and if life is not easy, I have hope but I hate the way I have to live. I have removed most of my facial hair but still have to live as a male. I confuse people frequently in public and it is very humiliating. I get up looking almost like a normal girl because of the estrogen I have taken and whatever made me the way I am and then have to make myself look as much as possible like a normal male. I have not been able to wear clothes that really fit since puberty. I always size my pants to my hips and then get to wear a shirt that is about one size too big. It becomes really hard to see yourself and I compare myself to other women and wish I could have their hair or didn’t look slightly more masculine because of x so I frequently get depressed. I don’t feel like I am super ugly but having to go around being seen as a male makes me feel like I look more ugly and masculine than I do. I hate it when someone tells me that I look handsome in an outfit I would love to burn.

    So.. I know I have a lot of image issues but I am far from normal in the transgender community so I really can’t compare. I don’t know what it is like to have a deep voice or lots of body hair or look really masculine.

    Honestly, the thing that has made my life hardest isn’t body issues at all but growing up being mocked and called gay. The way we treat men in this country who happen to like men or are somewhat effeminate is getting better but is still a horrible thing.

  • Nicki

    May 5th, 2013 at 11:15 PM

    I hate my body, it betrayed me, and still to this day it shouts my stigma for all to see and hear.

    I hate it so much at times I just have to lash out, to punish it for what it has done and has failed to do. In rage I hit, claw and punch it. The pain helps for a while, it soothes the self loathing, almost like a balm – but it never lasts. As the bruises heal and fade so the need resurfaces.

  • Vickie S.

    January 7th, 2017 at 9:35 PM

    Hi, I am writing a short play about body image and perception. I want to include the view point of someone who is transgender. Our community just lost a beautiful transgender young woman to suicide. Many of us are devastated. I was very touched by your words, and would like to use them in my show. If you are willing to share more of your thoughts with me, I would be grateful.
    Vickie S.

  • Shirley Katz

    October 24th, 2013 at 2:47 PM

    Self love doesn’t come endless from external validation. We have to find it in ourselves. What does that mean? Well its about noticing and taking responsibility for the internalization of what we think we see out “there”. In other words, not being at the whim of our egos..but deciding for ourselves what are out strengths and limitations. When you FEEL upset and down on yourself you CAN change the channel, change the focus of how you are feeling, change the things you are saying to yourself. A therapist can help you with that. Trans people have been conditioned to listen for and believe whatever others perceive of their bodies or their image, and they often need a therapist to help them become more independent in their self evaluation.

  • Barefoot Justine

    October 26th, 2013 at 8:39 PM

    Funny, I had written a comment for this before… and had forgotten. I came back to it today as I have been having obsessive body issues, and I mean VERY obsessive. It is odd to me that I have reached out and found this article twice. My recent body issues actually came over me in a fit of panic! Genuine panic. Our bodies, relationships to our bodies, even the hormonal balance of our bodies is complicated, so complicated I simply get overwhelmed and scared. It’s lonely out here on this frontier… and I don’t even know where to turn for help, comfort, or knowledge. It’s a drag…

  • Shirley Katz

    October 27th, 2013 at 5:53 PM

    Barefoot Justine, there are a lot of good therapists that can help in general to deal with any kind of anxiety and obsessive thoughts, especially if they come from a CBT background. There are many who are listed on this site, and you can find someone who lives where you do, or talk to a therapist who does online chat. Good luck.

  • Vincent S

    February 9th, 2018 at 11:55 AM

    There is noticeably a bundle to find out about this. I assume you made sure nice points in features also.

  • Emma

    December 12th, 2023 at 1:09 PM

    About to turn into 2024 and today is worst than it was in 2011 when this was written. Rights are being removed, trans people are being assaulted and even kids are murdered, Brianna may you rest in peace. Something needs to be done to stop this hate spree from going forward.

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