Facial Feminization Surgery and the Problem of Recognition

          In the 1950’s and the decades that followed, the dominant model of ‘trans surgery’ was organized around genital forms and transformations (Plemons, “Formations” 631). The genitalia were seen as “the site of a body’s male- or femaleness" and therefore the reconstruction of these organs were the means to ‘change sex’ (Plemons, “Description” 657). However, since facial feminization surgery entered the field in the mid 1980’s there has been a subtle shift in focus. While genital gender-confirmation surgery has remained at the heart of ‘trans surgeries’, facial feminization surgery has been steadily gaining ground (Plemons “Formations” 629). This shift in focus is quite significant as it might be understood as a shift towards understanding gender not as a matter of biological materiality, but as a product of social recognition (631). Facial feminization surgery takes the claim of performativity indicating that gender is produced through “contextualized acts of everyday recognition” and directs its intervention at the exact terms of that recognition (638). The aim of this essay is therefore to gain insight into this recognition that forms the basis of the practice.
            Facial feminization surgery is in medical circles understood as a broad range of bone and soft tissue procedures to “change the feature of a male face to that of a female face” (Altman 885) and it is not to be taken lightly: the procedures are aimed at radically altering the patient’s appearance, resulting in intensive surgery lasting up to ten hours (Talley 78). The procedures that are often performed include but are not limited to: forehead reduction, hairline correction, brow lift, rhinoplasty (‘nose job’), genioplasty (‘chin job’), cheek implantation, lip augmentation, mandible augmentation, chin reduction, and thyroid shave (Altman 885; Talley 78). In order to get the desired effect, manipulations often include breaking and severing the bones, removing sections of the skull for reshaping and resecuring the bones with screws and wires (Talley 78). Soft-tissue operations such as the face lift, neck lift, ‘fat grafting’ and skin treatments (chemical peels, lasers) might also be performed because female skin is usually thinner, softer and smoother, and wrinkles are perceived as a masculine feature (Morrison et al. 1768; Van de Ven 297).
            The origins of facial feminization surgery are considerably relevant to examine. The patient request that ultimately led to the development of the procedures came from a trans woman named Candice, who had undergone genital gender-confirmation surgery but returned to alter her facial appearance (Plemons, “Description” 658). Candice expressed that her earlier procedures had had a profoundly positive impact on how she experienced herself yet failed to impact how others perceived her in social interactions: she was still recognized as a man (658). This is understandable, given that a large part of the body is usually veiled from the public eye, while the face is often unconcealed and therefore functions as a point of reference and recognition (Talley 14). And even though the differences between biologically male and female faces are rather small, it generally takes a mere second to intuitively recognize that a face belongs to either the first or the second category (Van de Ven 293).
            There are of course various ways clothed bodies and habitus might signify gender differences, but one cannot underestimate the centrality of the face in social interaction (Plemons, “Formations” 632). This is exactly why facial feminization surgery is often chosen over genital gender-confirmation surgery, in order to “seek the transformative power of everyday recognition” and to “make transwomen’s identities as women recognizable to others” (629). Facial feminization surgery is thus understood as a transformational surgery because ‘woman’ is seen as an identity established by “acts of recognition and exchange in everyday life”, rather than someone’s reproductive anatomy (629).
            Following the Hegelian tradition, it is only through recognition that we become constituted as a socially acceptable being (Butler 2). However, as Judith Butler posits in Undoing Gender, the specific terms of being recognized as human are socially articulated and changeable, and sometimes the terms that deem some people ‘human’ are the same terms that deprive others from attaining that status (2). Morphology and sex, and more specifically the recognizability of that morphology and the perceptual verifiability of that sex, are all sites upon which humans are differentiated (2). The face in particular provides information about gender, ethnicity, age, attractiveness and emotional state, and in doing so determines our status in social exchanges and systems of power (Talley 13). Its features are the evidence upon which people are recognized and potentially stigmatized or celebrated (13). The face thus directly affects a person’s opportunities to improve in social standing and can therefore be seen as a form of both physical and social capital (13).
            While the face is able to open doors to opportunities, privileges and social circles, it can also compromise one’s value and disadvantage those whose appearance is not in line with dominant conventions of attractiveness or gender (Talley 14). Facial difference is often treated as a “socially deadly condition” (20) in which social interaction is threatened and important facets of human life (economic, social, bodily, emotional, intimate) are impacted (20). The ongoing harassment, pathologization and violence that plague specifically those who are ‘read’ or ‘discovered’ as trans is not to be underestimated and this is even more severe for trans people of colour (Butler 6). The consequences might include losing one’s children, losing or not being able to find employment and homelessness, and there are still laws in place that might result in imprisonment for trans people (215). To be able to have gender congruity, to be recognized as a woman, to be able to ‘pass’, then takes on large significance: “for many trans people passing is not simple a concept or ideal, but a necessary skill that enables them to avoid harassment, discrimination and violence” (Glover 348).
            It might come as no surprise then, that surgeons themselves ‘market’ facial feminization surgery as the ultimate way for trans women to pass and to be recognized as women (Talley 97). However, they forgo talk of actual violence and usually categorize passing as a way to avoid ‘social death’. The effects of gender nonconformity are described as deeply threatening to social interaction and, as was just discussed, these claims are clearly not unsubstantiated (21). Social interaction however, is only at risk by not passing in a culture that necessitates adherence to gender binarism. According to this way of thinking, people should fit into either one of the two categories, namely the one you were assigned at birth (99). Even if gender transition becomes a part of this discourse it follows that the trans person will migrate from one sex category to the other, and that they will try to hide or ‘repair’ any physical markers that do not align with their ‘new status’ (99). Facial feminization surgery as a practice relies heavily on precisely this gender binarism and imperative to repair.
            According to Elizabeth Spelman, the idea of repair is so attractive because it re- establishes our sense of (binary) order, our idea about how the world works and what it means to be human (2). As a result, the gender non-conforming face is usually treated as something to be fixed, healed and solved to finally produce a new, aesthetically ‘normal’ face that is closer to the cultural standards of appearance (Talley 31). It is thus not only a matter of repair, but also as a form of normalization: in trying to recover potential threats to social interaction, facial work produces human bodies that correspond to shared ideas about what faces should look like (28). When it comes to trans women’s faces, gender binarism informs that there are only two socially intelligible gender categories (Schippers 89). In this culture of sexual dimorphism, facial feminization surgery works as a “microsystem of social regulation” to transform facial difference into an appearance that is perceived as normal (Talley 35).
            That facial feminization surgeons rely on this theory of sexual dimorphism is not unproblematic, especially, and this cannot be emphasised enough, because their idea of a ‘normal’ female face is in fact a subjectively constructed ideal type (Plemons, “Description” 663). The way these surgeons and authors of medical articles on facial feminization put it, is that facial features have been thoroughly and objectively examined by anthropologists for the determinants of gender with the conclusion that the female face is unmistakably different from the male face in terms of size and shape. So much so, that patients wishing to feminize their appearance might be daunted with the sheer number of gender differences (Morrison et al. 1759). Surgeons claim for example that the female face is softer and more rounded, with arched eyebrows and smaller, shorter noses, while the male face is square and angulated, with a strong jaw and chin, straight eyebrows and a prominent nose (Altman 885). The reality is however more complex.
            When dr. Douglas Ousterhout, the founder of facial feminization surgery, was approached with the request for a face that would be recognized as belonging to a biological female, he had to understand what that would entail, given that he had never thought about the differences before. Ousterhout was a reconstructive surgeon trained to “make pathologically abnormal skulls and faces into ‘normal’ ones’” and ‘normal’ had never been a sexed or gendered category (Plemons, “Description” 658). Instead of questioning whether there are indeed significant differences, Ousterhout embarked upon his research to find out what these differences are (659). Because there were no medical sources available on the subject, he turned to physical and forensic anthropology, a field that looked at the chin, the nose and the forehead to determine whether human remains belonged to a biological male or female (660). In other worlds: at that point it only mattered if a face was male or female if a person was dead.
            Ousterhout first looked at early 20th-century anthropological descriptions of ‘the characteristics of the female face’, which were based on traditional anthropological methods that used the “art of personal judgement” in order to ‘sex the skull’. (Plemons, “Description” 662). Plemons argues that what emerged was a ‘feminine type’, whose existence did not depend on a particular form, but on opinions based on ideals of gendered beauty and desirability. This was a product of the collapse between the category of “the feminine as recognized by the desirable characteristic of beauty” and the female as biological category (663). Moreover, when they established the female and the male type in the early 20th-century, scholars had to ignore specifics belonging to race or age: only the European male touchstone remained (664). This means that to be a type, ‘the feminine’ had to differ significantly from ‘the masculine’. Any overlap was discarded as unimportant in order to hold on to the idea that men and women do not look alike (665).
            As a second step in the process Ousterhout wanted to take the specific parts of the skeleton where differences between masculine and feminine types were most clearly present and quantify them by applying statistical analysis (Plemons, “Description” 656). He believed for example that female’s foreheads were smaller but needed to know exactly how much smaller to be able to express the ‘feminine type’ as a statistically derived female mean. To be able to reach this goal Ousterhout turned to a longitudinal study of craniofacial growth amongst elementary and secondary school children that he had worked on when he was younger (666). The study used children identified as healthy and normally developing, and all 83 of them were white (666). Despite these facts, Ousterhout used the craniofacial measurements that this study produced to quantify the differences in the forehead, nose and chin that his earlier research had located. Even though both the earlier defined feminine type and the mean derived from this study were defined in relation to young, white female faces, the face that finally emerged from the statistical analysis was classified as ‘normal’, this way neatly obscuring its own history (Mol 121).
            Finally, Ousterhout visited the dry skull collection in the Atkinson Library of Applied Anatomy to see if he could apply his statistical norm to their skulls. However, this is an extremely difficult endeavour, given that the collection makes no distinction between population groups (Plemons, “Description” 668). The current curator of the collection comments that all one might do is to “assemble a line up stretching from masculine type to feminine type” to get some insight into the gradation, which is exactly what Ousterhout did. By using statistical measurements to objectivize anthropological knowledge and without any certainties about the sex of the skulls, Ousterhout performatively produced feminine skulls as female (668) and thus transformed the idealized feminine type into a biological category (659). This is how the young, white, extreme end of the scale became the fact of female sex. Or, more accurately, a Latourian ‘factish’ in which “forms of knowledge and value about the real body commingle and coproduce” (674).
            This seemingly objective ‘scientific’ explanation of sexual difference relies heavily on the theory of dimorphism that assumes real, measurable difference between men and women, while downplaying any possible variability within the two separate categories (Talley 92). Ousterhout had much to gain from this approach: by turning the feminine type into scientific evidence he could safeguard his practice from the criticism concerning subjectivity that is often aimed at cosmetic surgeons (Plemons, “Description” 661). By invoking science, Ousterhout was instead able to frame facial feminization surgery as working towards the same idea of a ‘normal’ outcome that guides genital gender-confirmation surgery and draw on its “therapeutic legitimacy” (Gimlin 62). If a trans woman has a ‘normal’ male face, then a set of procedures must be followed to make her normally female, which is notably everything that is not recognizably male. This way, the scientific grounding also helped him meet the goal of making his trans patients recognizable to themselves and others (Plemons, “Formations” 629).
            However, the implications are not insignificant, given that the field of facial feminization surgery as a whole still relies on Ousterhout’s theory of ‘the’ female face that does not actually exist. What does exist is a feminine ideal functioning as a point of surgical intervention, but these specifications are of course absent from the discourse of “natural and sexually dimorphic craniofacial difference” that is the basis of the practice (Plemons, “Description” 668). Interestingly, while Ousterhout’s work remains as a foundation, other surgeons do not each subscribe to the same monolithic standardized theory of sexual difference. They put their own emphasis on different procedures and parts of the body (Talley 90). Moreover, they acknowledge that ‘real’ women’s faces vary to a great extent and come in many different shapes and sizes (102). How Heather Laine Talley explains this contradiction is that these surgeons merely deploy the theory of facial sex difference in order to animate an imperative to repair by establishing trans women’s faces as “unacceptable, disfigured and outside the norm” (103).
            When discussing normalization, what is deemed normal and the norm, it might be added that norms in general are not necessarily all bad: we need norms in order to live and to understand how our social world needs to be changed (Butler 206). When we talk about what connects us as humans we are drawing from socially instituted relations that have been formed over time: the norm is what binds us (206; 219). However, sometimes norms constrain us in ways that could do harm to us. Normativity is a coin with two sides; on the one hand, it refers to the aims and aspirations that guide us, “the precepts by which we are compelled to act or speak to one another”, on the other hand, normativity refers directly to normalization: “the way that certain norms, ideas and ideals hold sway over embodied life and provide coercive criteria for normal ‘men’ and ‘women’” (206). Moreover, when we defy these norms, and trans women by the very nature of transitioning do, it is unclear whether one is still counted as living, valuable and real. The problem with ‘the norm’ as Butler puts it, is that it creates unity only through a strategy of exclusion (206).
            However, a small revolution has entered the field in the shape of dr. Joel Beck, who is not aiming to create ‘normal’ faces. Instead, he is focused on materializing individual desires for bodily change: to help his patients look like “the best versions of themselves” (Plemons, “Formations” 631). Dr. Beck does not identify his patients as people with distinctly male faces that need to be fixed and normalized, he instead focuses on the possibility of beauty or even exceptionality (631). While certainly working with ‘the norm’ or even trying to surpass it, the crux here is that he takes a distance from the historical discourse of pathologized transsexualism in which “gendered identity and sexed anatomy existed in mismatched binary pairs” (635). This is moreover not just a matter of semantics, Dr. Beck de-genders the face by for example rejecting mandible operations, because “beautiful women can have a strong jaw line” (636). What is most radical about this approach is that the patient does not need to get a ‘normal’ face in order to be recognized as a woman in social interaction. Moreover, there is also no need for them to reject one ‘wrong’ face for another ‘right’ one, which leaves the patient with a larger feeling of individuality and authenticity (637). This way trans people are no longer framed as sick, in need of treatment or suffering (638).
            To appreciate how important it is to go beyond this frame of the suffering trans person one has to understand its roots, which lie in the therapeutic model wherein only those experiencing psychological distress by failing to adhere to the gender norm should be allowed free surgery. For those trans people who seek insurance support for their medical procedures it is necessary to get a diagnosis of their ‘condition’ as described in the DSM (Butler 5). Only those stating they are in the ‘wrong’ body and suffering considerably because of their ‘condition’ are rewarded with ‘corrective’ surgery (Holliday and Sanchez Taylor 188). Because of this, the patient is placed in a double bind: by asserting autonomy and articulating surgery as a choice of embodied identity, they exclude themselves from ‘legitimate’ surgery, but in order to qualify legitimately, they need to present themselves as a suffering victim effectively erasing their autonomy (191).
            The idea that ‘trans surgeries’ are always necessitated by psychological suffering is problematic because it implicates that suffering is inherent to trans experience, that those who choose cosmetic surgery do not suffer and that suffering is central in making appeals to medical services (Heyes and Latham 181). Moreover, it is a highly specific type of suffering that needs to be invoked, namely a suffering that conforms to a normative understanding of sex-gender. The script a trans person needs to follow in order to get the surgeries they want typically requires them to express a desire for a “conventionally sexed body that aligns with a more or less conventional gender” (180). For example, trans men may only access breast removal surgery if they have proven to be suffering because they cannot be the normatively gendered person they believe themselves to be (184), whereas breast removal surgeries for male breast development are available in many Western countries on the grounds that to be a man with breasts is traumatic (184). Thus, if you do not fit with a normative understanding of sex-gender invoking your embodied identity as a reason to get a surgery is not an option (184).
            While Merleau-Ponty argued that ambiguity is the essence of human existence (169), within medical discourse and, as has been argued earlier, in social interaction, ambiguity is anathema (Heyes and Latham 180). As a result, diversity of trans experience is elided and trans narratives are constrained (174). Sandy Stone had already anticipated this problem when she wrote, “What is lost is the ability to authentically represent the complexities and ambiguities of lived experience” (295). These complexities include “positive experiences of sexuality”, “comfort with ambiguous anatomy” and “acceptance of a discontinuously gendered life”. (Heyes and Latham 183). To be ambiguous however, is often not to be recognized.
            As was discussed before, to be recognized is to be intelligible, to be a ‘real’ man or a ‘real’ woman. Yet in the case of facial feminization surgery, to be recognized is also to adhere to normalization (Butler 206). In this light there are certainly advantages to being less than intelligible (3). However, a liveable life needs a certain degree of stability and when the ‘I’ no longer adheres to the norm that makes one completely recognizable, it becomes to a certain extent unknowable, “threatened with unviability, with becoming undone altogether” (3). What Judith Butler proposes is that we might start by seeking out norms and conventions that maximize the possibilities for a liveable life and minimize the possibilities of an unbearable life of social - or even literal - death (8). Then, perhaps, we might go further and ask for a life that is more than just liveable: one that will give trans people their agency back and allows them to “emerge from fear, shame and paralysis into a situation of enhanced self-esteem in order to form close ties with others” (92).
            The presumption is that trans people are suffering and desperate to become a normatively sexed person, and that this is the reason they would request procedures such as facial feminization surgery. But, as Dean Spade asks: “What would it mean to suggest that a desire for surgery is a joyful affirmation of gender self-determination?” (21). What if the norms and conventions permit trans people to “breathe, desire, love and live”? (Butler, 8). Or, to go even further, that trans people would be delighted to just be transforming, regardless of stable gender category? (21). What I would like to argue in response to these questions is that dr. Beck’s approach to facial feminization surgery is a small but not insignificant step in exactly that direction. He has taken a surgical practice aimed at passing, one that is built on dimorphism and a totalizing narrative that reduces difference to suffering and transformed it into a practice that recognizes trans women not as women, but as active and desiring. By taking passing and adhering to the binary completely out of the equation, dr. Beck shows that perhaps the problem for trans women is not ‘not passing’, but ‘simply’ a lack of recognition.

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