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Page 8 of 20 Kant et al. Plast Aesthet Res. 2026;13:4

Table 4. Disambiguating BDD and gender dysphoria
Body dysmorphic disorder Gender dysphoria

Distress is caused by inconsistency with appearance
Focus on specific aspects of appearance contributing to a negative
overall self-image. Typically, these are consistent with dominant and secondary sex characteristics perceived to be at
Differences in societal beauty standards odds with one’s lived gender
presentation
Focus on specific perceived flaws is about a belief that this causes Focus on specific features believed to contribute to
the sufferer to be “ugly” or in severe cases, “disfigured” having the appearance of an individual of
non-congruent gender
The fundamental concern is an accurate perception
The identified area is being misperceived by the individual as
Appraisal that their body parts and appearance are not in line
wrong/problematic when it is within expected limits
with expectations for bodies of the affirmed gender
People with gender dysphoria may also perseverate
Actions taken to remedy the distress caused by BDD may also be
used by people who experience GD: mirror checking and on specific, granular aspects of their appearance that
Similarities in reassurance seeking, camouflaging/excessive makeup use, are imperceptible or affectively neutral to others
presentation avoidance and social isolation
People with GD sometimes report a “moving target”
of goals, whereby once one aspect changes, another
Both groups may seek out plastic and reconstructive surgery
becomes the focus of concern
BDD: Body dysmorphic disorder; GD: gender dysphoria.

BDD and gender dysphoria are commonly confused by not only lay people but some providers. However,
they are both distinct and have opposing treatment indications. Unlike BDD patients, who often
decompensate after surgical attempts to remedy perceived flaws in their appearance, patients with gender
dysphoria typically report high rates of satisfaction after gender-affirming surgery - often far above the
general satisfaction rates associated with other surgeries [14,51-57] . However, although there is no evidence
suggesting an elevated risk of BDD in individuals with gender dysphoria , the two conditions are not
[58]
mutually exclusive. Patients can experience both conditions, and screening should be considered for those
seeking any surgical procedure that focuses on external appearance, including the creation of a vulva or
phallus.

Outside of the context of gender-affirming surgery, patients with BDD who seek out surgical care often find
that their concerns are greatly heightened after surgery. The plastic surgery literature has amply documented
cases where this has led to multiple attempts to correct what is believed to be a flaw in the procedure or
healing process, one often not visible to others [49,59] . This last quality, where the perceived flaw is minimally
visible (or completely invisible) to others, can lead to conflict between providers and patients who are upset
that their surgeons cannot see what is so clearly apparent to them . This may be accounted for by subtle
[59]
differences in visual perception, although more research is needed [60,61] . Some research suggests that this may
be mediated for patients with mild to moderate BDD through the use of screening and presurgical
intervention .
[49]

Where BDD is suspected, teams should consider referring the patient for a formal assessment by a trained
evaluator. While BDD is not an absolute contraindication to surgery, it does require teams to be particularly
vigilant in ascertaining whether the patient’s gender dysphoria is separate from their BDD and whether their
goals for addressing their gender dysphoria are achievable using surgery. Where surgery is not currently
appropriate, patients should be provided with resources for accessing treatment and a plan for returning to
care. Where surgery is determined to be appropriate for an individual with BDD, providers should be aware
that genital surgery could potentially result in an exacerbation of BDD symptoms. There may be benefits to
pharmaceutical treatment .
[62]