Introduction
Facial feminization surgery (FFS) exists as a foundational element of transgender healthcare; distinctly utilized by transgender women seeking to match their external appearance with their gender identity, a medical “feminization” of existing facial features. Under rigid definitions, the Western chisel meticulously sculpts the ideals of FFS in a generalized template, which often overlooks the individual ethnic diversities of its patients. This constrained framework not only invalidates the unique identities of patients but also restricts research and innovation in the field,
narrowing the scope of surgical techniques and reinforcing exclusionary norms in transgender healthcare. Eric Plemons unveils this medical phenomenon in his work “Gender, Ethnicity, and Transgender Embodiment: Interrogating Classification in Facial Feminization Surgery,” studying the implications of a standardized surgical approach and its effect on transgender women.
The systematic approach of feminizing facial features through FFS shapes surgical results and subsequently the patient’s self-identification. The power dynamics and assumptions deep-rooted within cosmetic surgical procedures in FFS will uncover ingrained standards and an ongoing clash for inclusivity. While definitive biomedical guidelines provide medical structure for FFS providers, their unyielding practice, reinforced by biopower, jeopardizes diverse patient identities.
Biomedical Perspective: Universal Femininity
Through the lens of biomedicine, standardized criteria are necessary to produce feminine features that are socially accepted and recognized. Empirical data on the structural differences between skulls and tissues of males and females serves as the justification for this framework. Reinforcement of this categorical approach to femininity is to provide transgender women with the required features to conform to expected norms, promote social acceptance, and reduce cases of misgendering.
The backbone of FFS in the biomedical perspective: specified ideals of femininity. Widely accepted surgical publications state that femininity is achieved by “a narrow mandible, small chin, small, short nose, high zygoma [cheekbones], inclined palpebral fissure” (Raffani et al. 2016, 446). Further perpetuated by institutional medical training and textbooks, these often Western-centric guidelines are established within the medical operation system of surgeons and hospitals. Although outlining a specified set of medicalized norms for an established ideal of femininity, the surgical outline fails to incorporate how these ‘universal’ features are differentiated across the global population. Not purely an aesthetic preference, biomedicine
mistakenly promotes a homogeneous view of gender identity and beauty at the convenience of actionable procedures, and the expense of ethnic diversity.
The power dynamics instilled in FFS can be further clarified through the scope of biopower. Biopower involves the mechanisms through which institutions, such as surgical clinics and medical schooling, exert control over individuals' bodies and health outcomes. By generating a “normative” outline of femininity, institutions regulate the autonomy of transgender individuals seeking care.
Knowledge Production
Biomedicine holds extreme power in legitimizing what constitutes a feminine face, concentrated particularly in the hands of medical surgeons, who are seen as the primary authority of knowledge. Reliance on empirical data and years of training further support this perception of surgeons as hierarchical supreme in their field. Serving as the primary medium of understanding regarding the surgical process, surgeons can shape patients' grasp of self and their desired outcomes. A foundational principle of FFS outlines that “the female skull is understood as the fundamental structure from which the difference of masculinity can later emerge through
addition” (Plemson 2019, 10). Implied as an unchallenged law, the principle emphasizes the biomedical standing of viewing masculine features as an excess of anatomy, an addition to an existing baseline of female structure. Treating these established masculine traits as extraneous, it is recommended to remove such surplus of bone structure to achieve a more recognizable feminine image. A standardized approach allows structures of femininity to be readily identified and used to reinforce reproducible surgical outcomes, that often neglect non-white populations.
Abstract standards of femininity are further simplified in medical schools, hospitals, and professional associations, that regulate and endorse particular practices of FFS. The knowledge produced and “stamped” from these institutions certify, or arms, practitioners and methods that adhere to an established view and inadvertently alter the expectations of patients that enter their purview. The production and repeated application of standardized procedures further legitimize facial feminine norms, making them appear as universal ideals.
Patient Perspective: Navigating Pressure and Identity
Motivations and Conformity
Patients who seek FFS often desire surgical procedures to align their physical appearance with their gender identity. Driven by deep societal pressures to conform to standards of femininity, transgender women in particular face daily scrutiny of their outward appearance. The stigma associated with not belonging to unmoving binary gender norms and incidents of misgendering is a driving force for many FFS recipients.
Longing for recognition of true identity, Eric Plemson notes that “prospective patients [he] talked with said that they wanted FFS because, without it, others saw their masculine faces and recognized them as male. Many prioritized facial surgeries above genital surgery” (Plemson 2019, 11). Societal pressures result in a perceived necessity of FFS to achieve recognition of femininity, through observable features that align with “passing” for their internal identity. Visible established masculine features lead to continued misrecognition and persistent undermining of social identity in those seeking gender transition. The seemingly unorthodox
choice of patients prioritizing facial surgery challenges the established notion of genital surgery as the cornerstone of transgender healthcare.
Patient Goals: Validation and Empowerment
Patients undergoing FFS are attempting to make themselves recognized as feminine, while simultaneously succumbing to the forces of fitting into an established standard of beauty. However, patients also emphasize that femininity is culturally constructed, and they seek surgical practices that reflect these diversities. These pressures exist within the societal structure itself. Seeking the external validation and acceptance that comes with surgery, the standard of beauty is seemingly never-ending. In his work, Plemson touches on a personal anecdote of Cela, a transgender woman from the Phillippines, who felt profound pressure to conform to standards o feminity set by society. She recounts an encounter with a friend:
“Oh, you’re very pretty,” like she didn’t know I was a trans-. And then after I told her she goes, “Oh, you know you can take out that little bit of brow ridge that you have and shave your jaw down...” I looked up the jaw shave...and I go, “Oh my god, I could do this.” (Plemson 2019, 12)
Societal norms are coercive in guiding patient choices. The unrelenting need to “pass” as a gender through a limited view, demands conformity as a condition for social acceptance. Standards are internalized within transgender women, to correct perceived imperfections in their outward appearance. The instantaneous change of perception from “pretty” to requiring surgery after learning of Cela’s transgender identity highlights the pressures of erasing all signs of masculinity. More than just a physical transformation, FFS provides patients, like Cela, with the opportunity to avoid discrimination n and misidentification to better align with accepted feminine norms. FFS transcends a surgical process and becomes a means to negotiate societal standing and belonging in a world governed by gender binaries.
The Encounter
The clinical encounter between patients seeking to preserve fragments of their ethnic identities and surgeons adhering to Eurocentric norms reveals an entrenched tension that prompts a negotiation of mutual transformation.
Surgeons, guided by their medical training, approach FFS with the intent to align patient appearance with established norms, viewing ethnic features as deterrents to femininity. Consider Barabara, a transgender Greek woman, with an anecdotal experience seeking FFS: her surgeon noted that “ her nose’s distinctive ethnic character and its problematic masculinity were not only homologous, they were identical; Greekness was masculine” (8). Pursuing a neutrality of femininity, the practice of facial feminization seeks to erase ethnic features. Patients challenge these reductive norms by advocating for preserving their identities, which surgeons often resist, viewing this desire as compromising widely aesthetic standards. Equating ethnic characteristics with excess anatomy, or masculinity, surgeons implied resistance to compromise in standards, prompts re-evaluation of rigid criteria to consider a culturally relevant approach. This mutual transformation from clashing ideals, pushes the medical community towards inclusive practice, albeit with resistance.
Conclusion
The analysis of FFS underscores the interplay of deep-rooted biomedical norms and the diverse needs of transgender patients. Marginalization of ethnic features, often deemed incompatible with established femininity, profoundly impacts the self-identity of patients seeking an improvement in quality of life. A medicalized view of gender homogenizes femininity, surgeons are trained to view ethnic features as deviants of desired traits. This rigid definition of femininity bleeds into the societal framework, and shapes the experiences of patients, subjecting them to pressures that result in surgery as a necessity for acceptance.
Transgender patients seek to contest the replicable surgical process by advocating for an approach that encompasses individual identities. These patients reject the idea that femininity is normative and rather emphasize the importance of ethnic characteristics to personhood.
Clinical encounters reveal the deep-rooted biases and warping of surgical outcomes within transgender health care. Patients who resist the medicalization of their ethnic features are met with re-evaluations of their perception by surgeons and institutional publications. The prescriptive definitions of femininity and beauty in FFS shape the outcomes and daily experiences of transgender patients, who are navigating their transition at the likely cost of their ethnic identities.
Works Cited
Plemons, Eric. "Gender, Ethnicity, and Transgender Embodiment: Interrogating Classification in
Facial Feminization Surgery." Body & Society 25, no. 1 (2019): 3-28.
Raffaini, Mirco, M.D., D.D.S., Ph.D., Alice Sara Magri, M.D., and Tommaso Agostini, M.D.
"Full Facial Feminization Surgery: Patient Satisfaction Assessment Based on 180
Procedures Involving 33 Consecutive Patients." Plastic and Reconstructive Surgery 137,
no. 2 (February 2016): 438-448. https://doi.org/10.1097/01.prs.0000475754.71333.f6.
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