Facial Feminization Surgery - Part I
I've had a few interactions recently... and a lot of identical interactions over the past year... that have gotten me thinking about writing a series of posts on this subject. It's a VERY little discussed part of social and medical transition for quite a few male-to-female transgender women, and I think because it's often ignored or passed over for some of the higher profile stories and subjects out there. Hell, I spend all of my available activism and advocacy time on other issues, too, so it's not like I expect people to know more, but maybe I can help. I want you to know about facial feminization surgery (FFS).
FFS is a series or "suite" or surgical procedures that are intended to make a person’s face more closely conform to the typical appearance of their target gender. Yeah... these are some of the same procedures that some people get for cosmetic reasons, but FFS is an absolutely CRITICAL aspect of some women's' transitions. Some men, too, though FtM folks need this far less often than MtF folks. Check it:
So I’ve spent more than the past year fighting tooth and nail to get this procedure covered as medically necessary for me. It’s been REALLY intense, with half a dozen doctors and mental health professionals getting involved, lawyers, letters, phone calls, loopholes, and a lot of really shitty behavior on the part of Blue Cross Blue shield Vermont. I know the realities - I live them. I know the science - I have to. I know the law - it’s been required of me. I forget that a lot of people DON’T know any of these things, and so I still get a shock to the system whenever I mention it so someone. No matter how supportive, loving, and aware they are, I always get the same reaction - a mix of shock and incredulity. “You don’t need THAT! You look fine! You REALLY look like a woman!” Well… thanks? I really AM a woman, so what else would I look like? And are you suggesting that there are OTHER women who do NOT look like women, so they DO need it? Okay… yeah. I’m prickly here, I admit it. TANGENT TO EXPLAIN THE PRICKLY!!!!!
BEGIN TANGENT Transgender compliments. Ooooohhh…. They burn me up sometimes. I am surrounded by REALLY REALLY LOVING people who accept me. These compliments are almost ALWAYS intended to be nice, but they grate on trans people in general. We blow off steam about it in our private chats and stuff because blowing off steam to people trying to love you is really dumb. Examples include, “Wow! I would never have known [you are transgender]!” Okay. I mean, yay. That’s nice, but it suggests that a) I’m abnormal in that (you know more of us than you know you know), and b) that something has potentially changed now that you do. Another good one is when you comment on a body part - especially a butt or boobs - in a positive way, and then ask if they’re REAL. Seriously? Say you suspect your cisgender friend of stuffing her bra. Are you going to ask her about it? A somewhat related thing is when you clock someone as being trans or possibly trans, and the first thing out of your mouth is, “Hi, what pronouns do you prefer?” You’re showing that you’re a little educated on trans issues and that you’d like to be supportive. You’re ALSO telling the person in question that you’ve clocked them, reminding them that they are clearly different, and announcing their possible trans status to the room, some of whom might NOT have clocked them. First, listen. See how others are addressing them. If no one is talking to them, introduce yourself. Name and presentation will likely get you there. If THEN you’re confused, you may certainly ask politely. My ALL TIME FAVORITE transgender compliment is a variation of, “Wow! You look EVEN BETTER than ME!” Sure I do. So do a lot of other women. Are you telling them that? I spent an hour getting ready to go out in public today. Did you? The suggestion here lands as much in tone as in wording. There’s a supportive incredulity there that a dude could manage to present in a more attractive, feminine, or put together way than a cisgender woman. Again - I KNOW where people's hearts are when they use these, and that’s why I don’t spend my day calling people out for being nice to me, but I think it’s worth a run-on paragraph, because it’s NOT called out the way poor pronoun use might be. END TANGENT
So listen. I KNOW that you love me as I am. More and more, I love me as I am, too. I’m not having FFS for YOU though. I’m having it for me, for my family, and for the guy at the gas station, the lady at Dunkin Donuts, the drunk guy at the bar, and the ER doctor in Louisiana that I might someday need to ask for help. I have come a LONG way in the past four years, but I don’t tend to “pass” beyond a very cursory inspection. Usually, that’s okay. Shrug it off. Screw them, anyway. Move on. Some days, sure, but it’s RELENTLESS. The slow erosion of confidence and self esteem that happens over time. Think about the number of interactions you have each week with strangers. It’s a bunch. Now imagine if more than half of those interactions included clear double takes, confused or hostile looks, strange comments, or even POSITIVE changes in demeanor that clearly indicate that this stranger has recognized you as “other.” Is some of it about my perception? ABSOLUTELY, but my perception is my reality, and I’ve dug into this stuff to know that it’s a LOT of trans men and women’s realities as well. Try not to dismiss it, most especially the hostility.
The other thing to think about it safety. When I’m at church with you, or having lunch downtown, or visiting your home (which is lovely, by the way), all is well. You see me in these settings, and think, “geez, it can’t be that bad, can it?” Now think about the life of a cis woman walking alone at 1am in the city. She has a lot to be afraid of in our culture. The statistical percentage of trans people who experience physical assault, rape, and murder simply BURIES the ALREADY ATROCIOUS numbers for women in general. If I’m travelling internationally, there are places where being clocked can get me imprisoned or even executed, and that’s IF I make it into the system alive (which is rare). Wanna meet me at a busy bar after 8 or so? You don’t know it, but I park where I can see the bar and I sit in my car until I see you arrive. There are drunk bros inside who are just FULL of piss and vinegar. I’m not going in there alone. Just today, as I write this, a transgender man was brutally assaulted right here in Vermont - in our liberal mecca of Burlington, and he may not recover. The danger isn’t hyperbole - it’s VERY REAL. I’ve been in some hairy situations already, and the LEAST terrifying have been those where people have simply said horrible things to me in public. Thank God I didn’t have my daughter with me, and let’s talk about THAT!
The othering is one thing when it’s directed at me, and that thing is depressing, mean-spirited, eroding, and bad for me. When it extends to my six year old daughter, it is NOT tolerable in any way. Children sense EVERYTHING, and my kid is more empathic than almost any other person I know. She knows when moods are off, when people are uncomfortable, and when conflict is under the surface. The public reactions that I sense, she senses. On the days that I don’t put a lot of effort into my appearance, she also gets questions from peers about me - is your mom a boy or a girl? There are days when I don’t feel that I have the energy to put 30 minutes into my presentation and I don’t have the strength to blow off the comments and looks. On those days, Charlotte doesn’t get to go to the playground or to the restaurant or to the aquarium because her mom won’t bring her. My child should NOT be facing the discomforts that I do, simply because her mom is transgender, but she does. FFS could take a HUGE bite out of this for me and for her.
So, let’s talk about WHY this is a thing… and it’s not even a cultural thing, unfortunately. Activism isn’t going to fix this one - surgery is. Here’s why: the ability to differentiate gender visually is one of the very first things that human brains develop. It comes after identifying faces and before strained peas… months, not years. There’s simply no way to culturally attune is to gender variance at this age - it can’t be done. It’s innate. Gender ROLES and whatnot come with context, but human brains LOVE to categorize things. It’s kinda what makes us awesome. Green, round, big, soft, boy, girl. It happens before language happens, and this process is pretty permanently laid into our brains… even if we learn that male and female can be culturally flexible, we still sort people within one second of laying eyes on them. Gender identity (am I a boy or a girl) tends to solidify between 4 and 6 years, by the way. Our brains use something called secondary sex characteristics to do this sorting. There are a number of them, and the more of them we display, the more solidly the brains of people looking at us will categorize us on sight. Sadly, clothes, hair, and makeup are relatively WEAK indicators to our brains. There’s actually been a TON of research on the dozens of things your brain uses to differentiate gender in the fraction of a second when you look at someone. Here are the big ones:
The strong indicators are pretty noticeable once you become aware of them. One of the big ones is what’s called “brow bossing.” It’s well known to visual effects people trying to represent dumb people or even cavemen. Brow bossing is the bony ridge under and above the eyebrows of men. The more prominent this ridge, the more masculine the face. Start paying attention, and you’ll see that the “prettiest” models and stars have little to no bossing. The forehead slopes straight down to the eye sockets. Heavy brow bossing is a huge gender indicator, and it kinda tough to correct, because that ridge protects our sinus cavities. The very best FFS surgeons actually remove the top layer of bone and grind down the underlying skull, removing bone and sometimes even a sinus passage or two, then replacing the top protective layer. Sometimes surgical putty is used to build up an area around the repair to smooth the profile further. My brow bossing is pretty prominent, and I think will make the biggest difference for my day to day presentation.
Nose size tends to be a little larger in cis men than in cis women. In my case, a LOT larger. This just requires your standard “nose job,” which I’m quite looking forward to. Men’s hairlines are usually further back than women’s, and advancing that just a little bit can change someone’s appearance pretty impressively. Women's’ cheeks are usually fuller than men's’, and that’s a pretty easy fix with implants when needed. Men’s jawlines are more square, where women’s are either more pointed or rounded. This is addressed by grinding the base of the bone down a bit and sometimes contouring with putty. Here’s a funny one - did you know that the distance between a man’s upper lip and nose is significantly greater than the same measurement on a woman? Surgeons nip that space a little, and in the process, often turn the upper lip out just a smidge, creating a fuller, more feminine lip. The last big one is the Adam’s apple. Interestingly, men and women both DO have these, but they only tend to be prominently visible in men. Many trans women need that sucker shaved down, but mine’s never been really visible, so I’m not really fussed about it.
These are the secondary sex characteristics that are most commonly addressed with FFS. It’s very likely that I will need a little bit of all of this. It’s painful, it’s extensive, and it’s NEEDED in order to increase my safety, reduce my dysphoria, and improve my mental health. It’s not about vanity, and it’s not about “being pretty,” though who doesn’t like feeling pretty? Whatever your opinions on plastic surgery, it’s important to recognize that trans men and women pursue this option with a LOT more knowledge than most, and that these procedures ought to be thought of as RECONSTRUCTIVE, rather than cosmetic. We are having some embarrassing birth defects corrected by skilled, compassionate professionals.
In part 2 of this post, I’m going to talk more about my battle with the insurance company and WHY access to FFS is so difficult for so many right now.