Anita Rao
There is no better way to learn about socialization than hanging out with little kids. My 3-year-old nephew is a window into what it's like to look at the world with keen observation and almost no judgment. He notices everything. A change in my nail color, longer armpit hair, a large mole on my leg. These observations so far are neutral. As he grows and experiences more, he will start to absorb messages about what it means to have armpit hair, and why bright pink nail polish on his nails may not be read the same way as on mine.
While we all do the cultural work of shifting our rigid definitions of gender and what it means to look like a man or a woman, trans folks are experiencing the lived realities of being in bodies that are read constantly by other people, whether they look more masculine or feminine shapes, if they're called sir or ma'am, misgendered or mistreated.
Not every trans person wants or needs surgery to transition. But for some trans women, aligning external appearance with internal vision means pursuing a type of surgery that makes their faces reflect who they are.
This is Embodied — our show about sex, relationships and your health. I'm Anita Rao.
Facial feminization surgery is a set of procedures that reshape the face to have a more feminine appearance. You can include tweaks to the forehead, scalp, brow, cheeks, jaw, and Adam's apple, among other things. The procedure has been around for almost four decades, but it's grown in popularity in recent years.
Emma Ward
You know, a lot of people associate transitioning with just the gender reassignment part. And while that is important, nobody sees what's under your clothes — they see your face, they hear your voice. And so a big part of it for me was just really making sure that when I looked in the mirror, I saw the person that I was on the inside.
Anita Rao
Meet Emma Ward. She's a songwriter, producer and community manager. She got her facial feminization surgery in February of this year, after a lot of thinking and preparing.
Emma Ward
Essentially, after I, pretty much, committed finally, to go through with the transition, I went into like research mode, and I spent hundreds of hours looking up procedures and just like the timeline for how hormones affect the body. And in that research, facial feminization was definitely one of the areas that continued to pop up. And so, you know, from there, I was really looking for what surgeons kind of feel right to me, what are my options available to me in my area, and started really making a roadmap for how to accomplish that goal. Facial feminization was one of the many things on the list I had to plan for — quite possibly the biggest and most expensive one. So, definitely a lot of thought went into that planning stage.
Anita Rao
One part of that planning stage was finding the right surgeon, someone who was experienced with this complicated set of bone and soft tissue procedures, and also someone who would affirm Emma's experience, and walk her through the process of feminizing her face. She ended up finding a surgeon relatively close to where she lives out west, and stayed with him when he moved his practice to North Carolina.
Emma Ward
The analogy he used that really stuck with me is to think about it as percentages, you know — every person has a combination of what we would say are masculine and feminine features. And so, you know, the goal is to adjust enough of those to tip the balance, so that the majority of those features show up as feminine. And when you do that our brains are really good when we meet each other at subconsciously kind of assessing what we're looking at and assigning that label whether it's male or female to it. And so by tipping that balance more into the female, there's this subconscious recognition that you get from yourself, but also others get for you as well.
Anita Rao
That's so interesting. Did that then shape kind of how you talked with the surgeon about what your desires were and change what you wanted to tweak and change in your face? How did the conversation go from there?
Emma Ward
Yeah, it sort of gave me a toolkit to navigate the conversation. My focus going into it was — I still wanted to look like me. I didn't want to walk out looking like a completely different person. And, you know, I think, looking at how plastic surgery worked, even 20 years ago, you know, the outcomes were wildly different than they are now. And I think there's been kind of an evolution of how surgeons approach these kinds of procedures to make sure that everybody walks out looking natural, and they don't look like they were molded in clay or anything. He was very focused on that — I think that was a big part of the reason why I chose to work with him because he didn't want to do things that maybe I wanted, but wouldn't actually work with my features. And so he was all about — you want to consider how to make your face look as natural as possible.
Anita Rao
Another big consideration for Emma: cost. Facial feminization surgeries are typically classified as cosmetic procedures, instead of medically necessary ones, which means they're often excluded from insurance coverage. Some people turn to crowdfunding to raise the $20,000 or more to get their surgeries, others just can't consider it as an option. For Emma, getting insurance to pay took a lot of legwork.
Emma Ward
It is an incredibly expensive procedure. I knew from the get go, and when doing my research that I would not be able to afford it out of pocket myself. So I really kind of shifted my focus to trying to make a change in the benefits that my company offered. And so, you know, I did a lot of research, and I started looking into other companies that had, in the last few years, included that in their insurance offering - how did they go about that? - and what were the kinds of changes in the premiums that people were paying?
And I was actually very surprised that for some of the larger companies, there was actually no change in the costs — and I think a big part of that is trans people are a pretty small percentage of the total population. And out of that percentage, you know, not everybody is going to get these kinds of procedures. So when you zoom out, and you really look at it at scale, the amount that insurance companies would have to pay out for this is pretty negligible. And so I think a lot of those companies are successful in adding it and just folding it into their current plan.
So from there, I really started connecting with my benefits leaders at my company, and advocating for us to be more inclusive for the trans community. So I shared all that research. There was definitely some pushback, and it ultimately took upwards of two years to make the change happen. But thankfully, I work for a pretty progressive company. And, you know, they were very great about hearing me out. And ultimately, we had the right conversation, finally, and they committed to making the changes. And a couple months later, we updated our plan with that additional coverage.
Anita Rao
That's really incredible and smart of you to talk about the bottom line, which is, I feel like, what can really motivate folks to change policies at times. So I mean, what lessons did you learn through that process that you feel like other folks could take away from in terms of kind of getting companies to understand and take their healthcare needs seriously — even if they're not in the majority of what the healthcare needs are for that population?
Emma Ward
I think the fact that the percentage of people that would be utilizing such procedures is a big part of that. I think when you start talking about the kinds of things that facial feminization includes, like rhinoplasty — and just just a lot of people assume that that's like a cosmetic thing, and it's not needed. So, it gets really complicated because the question comes up of law - if we offer that for you, how are we going to deny somebody else who's maybe cisgendered who wants the same things?
And so helping them kind of see how it's not a cosmetic procedure, it's actually very important for your identity and how you see yourself — and there's a whole mental health aspect to it with dysphoria and how much they really like it — how big of a burden that is to carry around. And so that was kind of the first half of it. I think really the other main thing I learned was just a lot about how insurance companies work. And they're, by default, going to deny as much as they can — anything that's in the gray area that is not written in black and white. They're, by default, going to deny coverage for that. And what I found was that over 90% of cases that were denied, can be successfully approved through an appeal process. It's not something that many people are aware of, but I think that it is a powerful tool to have for anybody advocating for real change.
Anita Rao
After all that logistical prep to get the surgery paid for, and getting ready emotionally for an intense surgery to move muscles and shave down bone - what Emma felt at the end was peace.
Emma Ward
Before I got the procedure - everybody has good days or bad days. I think for me, there was a really long period of time where I couldn't even look at myself in the mirror. Just seeing the reflection not match up with how I felt on the inside was physically painful. It's not a good place to be with your mental health, and I think what's pretty amazing is that immediately after the surgery — I remember flying back on the plane, about a week and a half or two later, and even though I was still swollen and I had some bruising and stuff — staring at myself in the reflection of the plane window, and I could see the changes that had been made. And it was this like, overwhelming feeling of like calm and peace that kind of rolled over me. Just seeing those features that had triggered so much dysphoria for me no longer exist. And so of course, the more I healed, the better and better that feeling got. At this point, there's never been a time where I look in the mirror and I feel like there's a misalignment with my internal self.
Anita Rao
Emma's decision came from how she wanted to feel on the inside and out. But she said it was also a relief to no longer worry about people scrutinizing her gender. In both cases, she's not alone. Meet Aluna Vayne and Capri Celia, two other facial feminization surgery recipients.
Aluna Vayne
The most surprising thing about facial feminization surgery is how quickly I would forget what my old face looked like. Honestly, without pictures, without reference photos, even in the days following the surgery, I could hardly recall how I've looked beforehand. And that's because it was me — it was the person that I was always trying to see, but couldn't because of my dysphoria and because of the bones in my eyebrow and in my jaw.
Capri Celia
Probably the most surprising thing about having FFS has been the impact on my self confidence. Before I struggled with dysphoria surrounding some of my facial structure, and having the surgery was like really important for me to feel better about myself. No matter what your journey - having self confidence will allow you to flourish. I truly feel that in life if something will make you happier than you should go for it.
Anita Rao
That's Aluna and Capri. You can learn more about their stories on their social media accounts. Aluna shares her experience on her YouTube channel Aluna Vayne, v-a-y-n-e and Capri on Instagram. She's @caprisunbaddie - b-a-d-d-i-e. Zuriah Lee has also shared her facial feminization surgery story online.
Zuriah Lee
Are you guys ready: four, three, two, one. Omg! As you can see by the previous videos and by the title, I ended up getting facial feminization surgery.
Anita Rao
She's 27, and shares vlogs about her life on her YouTube channel. She lives in New York and her surgery in May of this year came from the desire to look and feel exactly like herself.
Zuriah Lee
Ever since I started my transition, I always wanted it. I always wanted more of a feminine face. Even though my face wasn't super masculine. I just know that I needed to tweak certain things because you know the female bone structure and a male bone structure is completely different. And so, therefore, I just wanted to knock out everything just so that once I get older, I won't have to go through the process — and currently, I'm in love with my face.
So, the vision that I had for my face was, I always wanted something natural. I didn't want to go too crazy with my face because I still wanted to recognize who I was, whenever I looked in the mirror. And that's what I got. And I'm super excited about it. I love it. Even though I'm not even fully healed yet, I'm in love with the results so far.
The whole European beauty standard — I never followed that since I am a Black woman. I believe Black women are the most beautiful creatures in the world. So therefore, I never looked at the European standard of it — like yes, it's cute. Like, do you know the small, pointy nose — but I just personally feel like for me as a Black person — yes, there's Black women that have small, pointy noses. But for me, personally, my family don't have small, pointy noses. So therefore, why would I get a small pointy nose, and then it just looks awkward? I just feel like the nose that I got is still very Black, is still very feminine, and it's beautiful. So, the whole European beauty standard, I feel like that was back in the day. And now, Black is beautiful, and that's just what I agree with.
My facial feminization definitely gave me more confidence. I don't have as much anxiety as I used to. If that, I don't even have anxiety anymore. I feel very confident being around heteronormative people. I feel comfortable being around everybody — I don't feel any type of way. Like, I'm just happy with my results. I'm able to go and do anything that I wanted to now, without having this thought in the back of my mind that somebody is going to try to clock me, and they're gonna try to fight me because they think that I'm fooling them or something like that.
Anita Rao
You can learn more about Zuriah on her YouTube channel Zuriah Lee. I want to take a moment and go back to something Emma said earlier that really caught my ear.
Emma Ward
Every person has a combination of what we would say are masculine and feminine features. And so the goal is to adjust enough of those to tip the balance so that the majority of those features show up as feminine.
Anita Rao
It made me wonder what defines a feminine feature, and who gets to decide what that looks like in the surgical world. These are some of the questions that occupy the mind of Eric Plemons. He's a medical anthropologist and associate professor of anthropology at the University of Arizona. He studied how facial feminization surgery has evolved over the past four decades.
Eric Plemons
What we think of now as facial feminization surgery or FFS really came to be in the early 1980s. And that's when a trans woman, who had been a patient at the Stanford gender clinic, and that had genital reconstruction surgery, came back to her surgeon a few years later and said: Listen, this change in my genital structure has been a really profound one for me personally, but nobody else sees it — and no one else sees me as a woman — and I think the problem that I have is not in fact, my genital structure, but it's my face.
And her surgeon was a plastic surgeon, and had no idea how to answer this question, but he knew somebody who he thought might — who was a craniomaxillofacial surgeon. So, those are folks who work on the structure of the skull and jaw. And this craniomaxillofacial surgeons' name was Douglas Ousterhout.
Anita Rao
Eric actually spent a year with Douglas Ousterhout. While doing research for his book, "The Look of A Woman: Facial Feminization Surgery and The Aims of Trans-Medicine." He learned that Ousterhout found the proposition of creating a gendered skull for surgical reference fascinating and challenging, and he went about developing it in a three step process.
Eric Plemons
The first one was: He looked at the way that physical anthropologists from the early 20th century found sites of sexual difference. So, you could think now about how archaeologists or forensic anthropologists might look at a skull and decide to assign a sex to that skull. So, he used those measurements, or places where sex distinction was located.
Then he went to this really interesting research archive, which was a series of orthodontic studies that was done at the University of Michigan, in the early part of the 20th century. And at the time, those studies were mostly for, as I said, orthodontists trying to figure out when faces stop growing, so they can decide when to put your braces on. So, we have these ideas from physical anthropology about where sex difference is in the skull. Then he used these numbers to make it, and then he used a skull collection at a dental school in San Francisco where he worked in order to kind of develop a bunch of procedures. And so that's where facial feminization, as we think of it now, first originated in the 80s.
Anita Rao
Eric's book traces facial feminization surgery, all the way to the present through stories of folks who got the procedure, ranging in age from their early 20s to late 60s, and through the experiences and perspectives of seven other surgeons. He interviewed them about their process and techniques - and one of the more complex topics that emerged: How clinicians differed in their definitions of what constitutes a feminine face, and where white beauty standards entered the conversation?
Eric Plemons
One of the things that I really found in my research is that this concept of femininity is a really interesting one because it's one in which the aesthetics of beauty and the biology of femaleness are collapsed to be one thing - and it's really difficult for us to pry apart what our kind of aesthetic sensibilities around beauty are versus some sort of biological claim to femaleness — and different clinicians think differently about that.
So, we can think about FFS and the feminization that it aims for as one instance of facial cosmetic surgery that is nearly always organized around some form of desirable femininity. So, we can think about: What is the motivating ideal of beauty and aesthetic desirability around all kinds of facial surgeries? And this becomes a really interesting issue on the question of race and ethnicity. It was around the early 2000s, that many plastic surgeons found themselves sort of accused of whitening or Westernizing faces — and as a response to that, we saw the growth of a field called ethnic cosmetic surgery — and what that really means is non-white people. So, whiteness in this field, like in many, becomes this unmarked norm. And then there's ethnicity, which is everybody who's not white, so that's one instance, in which you can see this tension being articulated between desirable, femininity and ethnicity or being a racially marked group.
In my time in the clinic, there were not a lot of people of color who came to the clinic when I was there. There are two stories that sort of stand out as a way to to demonstrate the way that ethnicity and femininity get played as being in opposition to each other. So, one of those was patients who had ears that stood out from their head, and they were defined in the clinical interaction as: Irish ears. And even though there's nothing about ears in facial feminization surgery, it was decided by the surgeon, and agreed to by the patient, that in order to feminize her face, he would change her Irish ears. So, in that exchange, Irishness and femininity are put at odds.
And then in the other case, there was a patient who had what the surgeon called: a Greek nose, and he explained to the patient in the interaction that as part of the feminization procedure, she would be losing her Greek nose. So there, what ends up happening is we have this sense that there is sort of an unmarked, white, feminine form underneath all of this ethnicity that can be taken away to reveal it. Whereas bodies don't exist in that way. There is no body that exists that is purely feminine without age or race, or ethnicity or health — but we tend to try to compartmentalize these characteristics and treat them as though you can speak about them that way there's such a thing as femininity that doesn't have a form.
Anita Rao
These reflections on femininity, race and ethnicity in the operating room are just one layer of the facial feminization conversation. Another that's been addressed by trans activists like Laverne Cox: How the surgery might further a gender binary?
Eric Plemons
A lot of the critiques that I heard were from other trans women who are opting not to have it. And so as you say, one of the criticisms was that FFS is a technology that narrows the possible forms of being a woman, so that those people whose bodies do not conform to that norm become even more suspicious. Because the idea is: there's a way to look more feminine — you could simply go and have this really invasive major surgery. And so those people who choose not to then they're challenging or making visible gender variants in a way that some people are uncomfortable with.
So, one criticism from within the trans community is: This is making impossible the types of gender variation that would lead to trans liberation. Ultimately, that if varieties of gender become acceptable, then it makes it easier for more people to live the lives that they want and conforming to a narrow idea of beauty or femininity forecloses that possibility.
Another critique that I heard often was that FFS is very expensive, oftentimes more expensive than general reconstruction surgery. FFS is for the resourced, and therefore leaves out those bodies that are already marked as suspicious bodies — those women of color, poor women, women who are sex workers — folks who don't have the opportunity to access these technologies are left even further behind as a result of it.
Anita Rao
You were saying that it is a really personal decision for folks, and we are all living in this politicized, gendered world. And so individual — there's this distinction between individual choices and just what it feels like to go out in the world and have who you are affirmed by how other people see you day to day. And one person can't change that big societal, constantly moving and evolving, definition of gender.
So, as you kind of look at trans medicine, and how the power of it has changed and evolved over time, who do you see as really having a say in kind of what gets affirmed and what doesn't? And how trans folks can kind of have a voice in that conversation? Do you feel like they do at this point in time?
Eric Plemons
I think absolutely. One of the things that's been true about trans medicine, from the very beginning, is that it's largely been driven by patient requests, demands and desires. We know that surgeons certainly — up until recently who have been specializing in this field — are often ostracized by their peers and lose a lot of credibility for their work with trans folk. So, even though — yes, surgeons do often get very rich or become famous in this little universe — there has not been a lot of motivation for them to get involved beyond the motivation that's coming from trans folks themselves.
And so that has been a really significant impact in shaping what's available and to whom, but we live in the United States, and so a lot about how healthcare works is about money and insurance. And so one of the big changes that's happened in trans medicine since 2014, is the Affordable Care Act said that it would provide coverage for certain forms of gender transition —and part of the trouble is trying to define what that word and phrase means. And many, many more states Medicaid now cover various procedures under the sort of title of transition. Again, that's a kind of a fuzzy word, but as more surgeons are trained, as more clinics come online, as more insurance coverage increases, we're seeing an expansion of access.
Anita Rao
As we said earlier, there's also been an increased demand for facial feminization surgery in recent years. Eric says that fact says a lot about how we socially construct sex and gender, and how medical care for trans communities has adapted to reflect that.
Eric Plemons
FFS confronts us with the question of: What is trans medicine trying to do? If it's trying to take bodies and make them conform to a 1950s definition of what sex difference is, then it's going to look like it has looked broadly in this country for the last 60 years, which is to prioritize genital reconstruction, to prioritize cross-sex hormones, and to imagine that the aim of a trans person when they go to the doctor is to switch from one distinctly identified sex to the other.
But if you actually prioritize trans folks in clinic and say: What is it that we're asking for from clinicians? When we go there, a different sort of picture emerges, and you can take seriously then the question of gender not as a problem of an individual body on an operating table, but a problem of an identity that's created in social interaction. And if you do that, then the aims of trans medicine change. And what it means to provide good care is not then about treating that individual body on the table like an isolated unit, but treating the body as a social unit that gets its meaning from exchanges with other people. And that's what I hope to make clear in thinking about FFS and taking seriously the claim that it's through changing someone's face that you can change their sex or change their gender.
Emma Ward
It's easy, especially when you're first transitioning to fall into these traps that are created — these expectations that are created from honestly [how] men view women and how they should be.
Anita Rao
That's Emma Ward again. Since transitioning and getting her facial feminization surgery, she's reflected on her own process and femininity.
Emma Ward
Part of my evolution's really been having to go through all those kinds of pressures and really like internally challenge them with myself. And, you know, learn that that's an outside person trying to tell you how to be and how to act. And who I am and my femininity comes from within — and it's unique to me. And so it's taken years, but I've kind of settled into who I am and really figured that out more, and it's much more of a natural thing than trying to live up to somebody's expectations.
Anita Rao
Here's Emma's advice for other people thinking about facial feminization surgery.
Emma Ward
Definitely have someone to talk through it with — I think it's always a good idea to speak with the therapist, and really kind of flesh out the dysphoria you're feeling and where it is and why it is before you commit to such a big procedure. I know how overwhelming you can get and how, sometimes, how hopeless it can feel. And I just want everybody to don't give up, because there's always a way. It takes an incredible amount of willpower, but the reward at the end is so huge. Not having to carry that extra weight around of the image you see in the mirror not matching up with your internal one — like being able to let that go is life changing.
Anita Rao
What goes into facial feminization surgery can look different for every body. So, before we close — a few other perspectives on how to prepare from two people we met earlier: Aluna and Capri.
Aluna Vayne
My advice is this: First, take lots of pictures. And secondly, give yourself time. because you're going to be swollen like a puffer fish when the surgery is first completed, and your face will change over the coming weeks and months and years. Give yourself time to relax and enjoy the process.
Capri Celia
Number one: Do your research. Number two: Know your aesthetic goals. For yourself as an individual, it's really important, because you don't want to go into it expecting to be someone else. You got to embrace who you are and your features that make you beautiful. And also I would say to love yourself along the way. And it's really important to not forget that. Sometimes we can put our goals ahead of where we are in the moment and forget to be content with what we're doing and who we are at that time. So, I think that the healing process can be really difficult, and that's something that I learned also throughout this process that was very hard for me, but I got through it, and I'm super, super happy, and my life has changed as a result. So, I'm really happy to be on the other ends of that and love my reflection.
Anita Rao
Embodied is a production of North Carolina Public Radio WUNC, a listener supported station. If you want to lend your support to this podcast and WUNC's other shows on-demand, consider a contribution at wunc.org. Now, incredible storytelling like you hear on Embodied is only possible because of listeners like you.
Kaia Findlay produced this show with help from our intern, Anthony Howard. Amanda Magnus is our editor. Jenni Lawson is our sound engineer, and Quilla wrote our theme music.
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I'm Anita Rao, taking on the taboo with you.