Abstract
Facial feminization surgery (FFS) is a set of bone and soft tissue procedures intended to feminize the faces of transgender women. In the surgical evaluation, particular facial features are identified as ‘sex specific’ and targeted for intervention as such. But those features do not exhibit ‘maleness’ or ‘femaleness’ alone; they are complexly entwined with morphologies of ethnic classification. Based on clinical observation, I show how the desired feminine ideal conflicted with facial characteristics identified as ‘ethnic’. In FFS practice, ‘masculinity’ and ‘ethnicity’ were entangled as the constitutive outsides by which desirable ‘femininity’ was articulated. I argue that surgery that self-consciously enacts a patient’s move away from physiognomically identifiable ethnicity in order to achieve an ostensibly unmarked and neutral femininity becomes not only a process of feminizing the face but of whitening it, regardless of whether ‘white’ features are the express desire of the patient or aim of the surgeon.
Facial feminization surgery (FFS) is a set of bone and soft tissue surgical procedures intended to feminize the faces of trans- women. 1 This growing contemporary practice was first developed by San Francisco cranio-maxillofacial surgeon Douglas Ousterhout 2 in the early 1980s and for the past two decades has been moving from the margins of trans- women’s medically mediated transition increasingly toward its center (Altman, 2012; Berli et al., 2017; Morrison et al., 2016). The surgeons who perform these procedures and the patients who undergo them share an understanding of facial appearance as fundamental to sexed identity. It is common sense, they argue, that a person is a woman not because of her genital anatomy but because she is recognized as a woman by others in her everyday life. Because our facial appearance is central to how and as what others see us, producing a recognizably feminine face is a means for producing recognizable women. FFS is a form of surgical sex reassignment animated by a performative model of sex; it is aimed at eliciting affirming and productive forms of gendered recognition (Plemons, 2017).
Among the surgical procedures frequently employed in medical transition – genital, chest, and breast reconstruction, most popularly, but also voice modification, hair removal and transplant, and body sculpting – FFS poses a unique set of challenges both for its incorporation into the dominant philosophy of transgender therapeutics and for scholars studying their politics and practice. While genitals, chests, hair, voice, and body shape are features that convey information about us to others, none of these signifies so much or so centrally in everyday life as do faces (Edkins, 2015; Plemons, 2017; Talley, 2014). 3
Because faces are so complexly polysemic, it takes considerable and consistent rhetorical work to categorize individual faces or collective face-types into stable groups (to say, for example, ‘male faces look like x and female faces look like y’) (Black, 2011). The logic of FFS depends upon the assertion that faces can be categorized and understood in this way. Although FFS is explicitly focused on sex-signifying characteristics, facial features don’t always or only convey information about a person’s sex. The discourse and practice of FFS has struggled to address the ways that the sex-specific characteristics it targets are mutually implicated in physiognomies of age and ethnicity. It has been difficult to contend, therefore, with the ways that procedures aimed at feminizing a face also and at the same time alter the appearance of a person’s age or ethnic heritage. While youthfulness is widely understood as part of desirable femininity – one American FFS surgeon explained these as selfsame by telling me that effectively all facial rejuvenation surgery is feminization – in this article I focus on the clinically emergent status of femininity in relation to features that surgeons and patients in my field site identified as ethnically marked. Following Cressida Heyes’s (2009) assertion that, ‘All cosmetic surgery is ethnic’, here I examine how and when surgeons and patients identified a relationship between ethnicity and the feminine ideal that animated the practice of facial feminization. Focusing on how masculinity was operationalized as clinical problem in one patient’s case, I show how concepts of masculinity and ethnicity became entangled as the constitutive outsides by which the form and ideal of desirably youthful femininity was articulated.
While many scholars have critiqued the use of surgical interventions to produce hegemonic ideals of bodily beauty (Blum, 2003, 2005; Bordo, 1997; Braun, 2009; Morgan, 1991), others have examined surgery as a means for cultivating the health benefits of self-esteem (Edmonds, 2010; Featherstone, 2010; Gilman, 1999; Gimlin, 2007; Haiken, 1997), enhancing the body’s economic productivity (Albrecht, 2016; Edmonds, 2007, 2010; Serlin, 2004), as a demonstration of agency and tool of self-actualization (Davis, 2003a; Negrin, 2002), and as a locally specific practice that both incorporates global forces and materializes local ideals of bodily form and value (Edmonds, 2010; Holliday and Elfving-Hwang, 2012; Holliday et al., 2015; Lenehan, 2011). The availability of body-altering techniques incites a ‘cosmetic gaze’ through which all bodies are seen as improvable through intervention (Wegenstein and Ruck, 2011). Some scholars focused on race, ethnicity, and facial cosmetic surgery have read the surgical consumption of non-white patients (usually women) as motivated by an aim of ‘whitening’ or ‘Westernizing’ their appearance, thereby reading surgical self-making as an embodied materialization of race, gender, class, and (post) colonial politics (Aquino, 2017; Davis, 2003b; Dull and West, 1991; Hunter, 2011; Kaw, 1993; Perry, 2006). Others have challenged the assumption that women of color use surgery in a distinctly different way than do white women (Gulbas, 2013; Pham, 2014), suggesting that to read all surgeries undertaken by non-white women as mimicry of a desired whiteness depends upon an assumption of ‘whiteness’ or ‘Westernness’ as an aesthetic ideal (Davis, 2003b; Heyes, 2009; Luo 2013; Zane, 1998), one that, as Holliday and Elfving-Hwang (2012) argue, is not available even to most white people.
One clinical response to critiques that surgery aims to ‘whiten’ by obscuring features associated with non-white ethnic or racial identities has been the emergence of ‘ethnically appropriate’ cosmetic surgery. Promoted as a good of multiculturalism, ‘ethnic cosmetic surgery’ looks to improve aesthetics while retaining patients’ ethnic identity. ‘Ethnically targeted cosmetic surgery’, writes Victoria Pitts, ‘now aims to rethink Eurocentric beauty ideals in order to preserve the ethnic features of the person, and to “honor” her or his racial heritage’ (2006: 39). It should be noted that in this literature, ‘ethnicity’ is treated almost solely as the property of non-white bodies – and, more specifically, non-white faces – whose distinctively marked ‘ethnic’ features are in danger of being effaced in the process of beautification.
While claims and practices of ‘ethnic cosmetic surgery’ aim to decenter ‘Eurocentric’ notions of beauty, they are motivated by a beauty ideal that ‘enhances’ or ‘improves’ a face that is already recognizably female. It is about making women – usually – more beautiful. The ‘femininity’ that underwrites FFS, however, is distinct in that it refers to the production of both a desirable aesthetic and, most crucially, to a recognizable femaleness. ‘Femininity’ is a concept in which biological femaleness and aesthetic desirability collapse. 4 It is the desire to be recognized as a woman through being seen as female that motivates FFS patients and constitutes claims for its therapeutic efficacy (Berli et al., 2017; Plemons, 2017). As opposed to the cosmetic procedures described by Pitts above, FFS is not considered an ‘ethnic surgery’ because practitioners neither make an express effort to erase nor to preserve ‘ethnically’ specific features, per se. Rather, as I show below, the equation of femininity to whiteness renders gender and ethnic interventions simultaneous.
Materials and methods
The research discussed here was carried out between 2010 and 2011 when I spent a year conducting ethnographic fieldwork in the offices and operating rooms of two FFS specialists in the San Francisco Bay Area. During my time in their offices I observed preliminary consultations, pre- and post-operative patient exams, accompanied surgeons into the operating room for dozens of procedures, traveled to conferences where surgeons presented their work and prospective patients learned about and scheduled procedures, and conducted formal and informal interviews with (prospective) patients, clinicians, and their critics in the clinic and elsewhere. I concentrated my research efforts in the office of Dr. Douglas Ousterhout and observations and patient interviews that I relate here happened in his office.
Of the 29 patients I formally interviewed in the clinic, only two self-identified their race and/or ethnicity 5 as something other than white/Caucasian. The overwhelming whiteness of the patient population that I observed is reflected in clinical literature on FFS. 6 It is also consistent with estimates of transgender-identified Americans by race, in general (Flores et al., 2016). 7 Ousterhout explained his FFS patients’ overwhelming whiteness as a reflection of unevenly distributed financial resources. The high out-of-pocket cost of FFS selected for those with money, and American wealth remains concentrated among white folks (Williams, 2016).
Despite being developed using the metric norms of American children of Northern European heritage (Plemons, 2014), the fact that ethnicity and gender are co-constitutive social categories grounded in physiognomic difference was almost completely absent from everyday clinical discourse. Instead, facial ‘masculinity’ and ‘femininity’ were discussed as though they were racially and ethnically unmarked and universal descriptions of binarily sexed bodies. For example, a recently published surgical paper defines ‘feminine’ faces as those with, ‘A narrow mandible, small chin, small, short nose, high zygoma [cheekbones], inclined palpebral fissure [eyes whose distal canthus is slightly higher than medial canthus – sometimes called ‘catlike’], and arched eyebrows’ (Raffaini, et al., 2016: 446). There is no mention of how these ostensibly universal feminine characteristics are differentially distributed among world populations; this is simply how feminine faces look.
During my time observing clinical appointments, patients’ facial features were rarely discussed as carrying any racial or ethnic specificity. Instead, they were interpreted as primarily ‘masculine’ or ‘feminine’, for it was their faces’ sexually distinct characteristics that patients were there to change. Though the surgeons I worked with acknowledged in professional conference presentations that facial features carry ethnic and racial connotations, and discussed them as such in conversation with me when I asked, there were only three occasions in the exam room during which a patient’s facial features were explicitly discussed as racially or ethnically specific. The scarcity of this discussion mirrored the lack of phenotypic diversity among patients in FFS surgical literature and reflected the shared whiteness between the surgeon and patient population. Hegemonic invisibility in the form of assumed neutrality is central to the definition of whiteness, a category constituted through excluding racially or ethnically marked others rather than one with an identity or bodily form unto itself (Frankenberg, 1993; Hartigan, 1997; McGuiness, 2000). Patients’ whiteness – their ostensibly neutral status as non-ethnic, non-raced people – was produced precisely by its absence from conversation: it was so normal as to require no comment at all. ‘Ethnic’ features, however, warranted special consideration.
In the clinic, ‘ethnic’ features were those that patient and surgeon linked to a group whose characteristics they identified as being at odds with the animating ideal of aesthetic femininity. In all cases, the problem with ‘ethnic’ features was that they were excessive compared to the demure femininity that patient and surgeon desired. As troublingly ‘ethnic’ features were identified, the ideal feminine form grew ever more particular. In practice, the ostensibly binary and universal ‘men look like this’ and ‘women look like that’ explanations of facial sex difference were both tempered by the necessity of accounting for ethnic difference, and reinforced through surgical plans that rendered ethnicity and masculinity isomorphic. In the process of ridding their faces of masculine characteristics, patients learned that their ethnic characteristics would be removed, as well.
On one such occasion, Barbara’s surgeon described her ‘Greek nose’ as an undesirably masculine one. When surgically removing the ‘masculinity’ from her nose, her surgeon acknowledged, its Greekness would also be removed. Her nose’s distinctive ethnic character and its problematic masculinity were not only homologous, they were identical; Greekness was masculine. Another patient named Beth longed to change the protruding ears that, according to her and her surgeon, marked her as both male and Irish. 8 Both agreed that pinning Beth’s ears was an important part of feminizing her face; they did not discuss the procedure as simultaneously altering her recognizable Irishness though it was clear that such a change was an unintended effect of FFS. The marks of theses patients’ Greek and Irish heritage were opposed to the ostensibly unmarked and neutral ideal of femininity. Patients could be one or the other, but not both. To oppose ethnicity with femininity is to whiten the definition of feminine form through the exclusion of ethnic specificity.
This article focuses on the final case in which ethnicity was explicitly discussed as facial masculinity. The patient, whom I call Cela, wanted to improve and feminize her face by softening what she called her ‘Filipino jaw’. Cela felt that her jaw made her appear older and ‘harder looking’. Her surgeon reduced her jaw as a key element of feminization. Leveraging a definition of ‘the feminine’ as a form that is developmentally prior to the emergence of either masculine features or ethnically marked ones, Cela’s masculinity and ethnicity – like and as each other – were framed as excesses of her face that could be literally cut away to reveal an imagined ethnically neutral and youthful feminine form within. Though focused on just one case, the fact that a similar discussion did not happen in consultation with ethnically unmarked patients forms the corollary to my argument. In these other cases, the absence of ‘ethnicity’ shored up an understanding of universal femininity as comprised by neutral and normal whiteness. ‘Silence itself’, Foucault (1978: 27) writes, is ‘an element that functions alongside the things said, with them and in relation to them within over-all strategies.’ The assumption and subsequent materialization of an ethnically neutralized form of facial femininity is such a strategic silence.
Excess material
Facial feminization surgery infrequently involves the addition of materials such as implants or transplants; it is nearly always a project of subtraction. 9 Features seen to signify maleness and masculinity are coded as problems of excessive and unwanted bone and soft tissue. When these structures are reduced, resected, or removed, the essential feminine form within is revealed, literalizing the well-worn description of the trans- woman as trapped inside the husk of a male body. As opposed to formulations of sexual difference from Aristotle to contemporary medicine that treat the female body as an inferior or derivative version of the male-body-as-neutral (Ellis, 1913; Epstein, 2008; Laqueur, 1990), in FFS discourse, the female body – and more particularly, the female skull – is understood as the fundamental structure from which the difference of masculinity can later emerge through addition. 10 This description mirrors the anthropological and orthodontic literature upon which Ousterhout originally formulated the sites and forms of FFS intervention (Plemons, 2014). In this literature, the immature skeletal form of preadolescence is equated with gracility and femininity (Geller, 2005). During puberty the common immaturity of childhood is, in some bodies, covered over by the bony thickness and angularity associated with testosterone. Without the testosterone additive, other bodies retain their gracile and relatively ‘underdeveloped’ feminine characteristics. Containing the form of its own past, within the adult trans- woman’s skull is a feminine form waiting to be recovered.
Just as masculinity is a problem of excess, in the surgical clinic ‘ethnic’ features were also framed as layered on top of an ostensibly neutral and normal feminine within. The early 20th-century physical anthropology literature that is used in FFS discourse to delineate osteological sex distinctions was shot through with racialized understandings of the body, and their idealization of European beauty as the very definition of female form (Fee, 1979; Gere, 1999; Stepan, 1986). As such, racial politics inhere in received scientific claims to sex difference, becoming the common sense of bodily – and especially facial – classification (Wegenstein and Ruck, 2011). In the process of the physical exam, ethnicity was materialized and represented as a thing: a palpable quality of the face discernible (and diagnosable) in particular morphological sites (Mirivel, 2008). As Judith Butler has argued, ‘To claim that sexual difference is more fundamental than racial difference is effectively to assume that sexual difference is white sexual difference, and that whiteness is not a form of racial difference’ (1993: 182). During my time in the surgical clinic, neither patients nor surgeons spoke of feminizing procedures as ‘ethnic cosmetic surgery’, nor were ‘ethnic’ features targeted as such. It wasn’t the Greekness of Barbara’s nose, the Irishness of Beth’s ears, or the Filipinoness of Cela’s jaw that were problematic, per se. Rather it was that each of these distinctive features were also seen as unfortunately masculine.
Cela
Cela underwent multiple-procedure FFS with Ousterhout in 2005. I met her in 2011 when she returned to his office to inquire about a potential revision to her jaw surgery. In the initial procedure, the posterior width of her mandible (the squareness at the back or angle of her jaw) had been reduced to give her face a ‘softer’ and more rounded shape. She worried that over time some of the squareness had returned. Ousterhout agreed to do the revision surgery and left open the possibility that he might also remove a portion of Cela’s masseter muscle to further narrow her face.
Despite the need for revision, Cela told me in an interview that she had been ‘very pleased’ with the results of her first surgery. She called her facial surgery a ‘life-changing’ operation, but she described its effects differently than did other FFS patients. Most past and prospective patients I talked with said that they wanted FFS because without it, others saw their masculine faces and recognized them as male. Because they longed for recognition of their feminine identity, these patients regarded FFS as crucial to their transitions. Many prioritized facial surgery above genital surgery – the procedure often considered to instantiate if not define medical ‘transition’ – or to the exclusion of that procedure altogether. When FFS helped them to achieve their aim of being recognized as women in the world, they declared that it fundamentally changed their lives: it made them women. By contrast, Cela had consistently been recognized as a woman – or, as she said, ‘passed’ as a woman – long before her FFS procedure. For her, facial reconstruction was ‘life changing’ for other reasons. I’ve always been passable. You know, I think at that time [of the first operation] I just had way too much disposable income. I think I had the extra money and I found this surgery and I go, ‘Let me improve myself.’ You know, because I have girlfriends who are born female and they look good but they still want surgery. I think it’s not really the fact that I felt like, ‘Oh, I look like a guy.’ I never felt like I looked like a guy. I never thought [FFS] would really change my life, because I was still feminine. I’m short. I don’t have broad shoulders. So I pass anyway. [The other woman] was very passable and she goes, ‘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.’ Like I said, anything to look prettier. I looked up the jaw shave and [Ousterhout] came up. And I go, Oh my god, I could do this.
Cela attributed the recognition of her femininity to the ethnically distinct characteristics of her face. For some reason I feel like because my face before [surgery] always fit in with my race, I never really got spooked [recognized as male]. Back then – with the strong jaw and stuff like that – I still passed [as female] because, you know, Filipinos we don’t have the Northern Asian face so we’re a bit harder looking.
The claim made by both lay persons and FFS experts that a ‘wide’ or ‘square’ jaw is a telltale sign of maleness applies to some faces, but not to others. In Cela’s telling, her ‘strong jaw’ marked her as Filipino, not male. The sex-distinctive aspects of Cela’s face – if indeed they existed – must be located elsewhere. She considered herself fortunate, however, that the American and distinctly non-Asian audience of her face was less able to recognize these redistributed signs of facial sex difference; they could not ‘spook’ her.
11,12
[Before surgery, my face] never bothered me. I think being Asian helped. I know some transsexual Asians that still look very masculine, but I think I looked feminine anyway. It’s amazing how people respond to what they perceive as attractive or exotic or something. Especially in San Francisco. Everybody there has an Asian fetish for some reason. They all like Asian girls.
Despite the reliable and desirable recognition of her femininity – demonstrated most clearly to her in the form of men’s sexual attention – when Cela approached Ousterhout for surgery, he recommended the suite of procedures that he used to transform trans- women’s faces from male to female. Cela underwent them all: her anterior frontal bone was set back into the frontal sinus to reduce the prominence of her forehead, a rhinoplasty was performed to augment the bridge of her nose and bring down its tip, a wedge of bone was removed from her chin to reduce its height, and her upper lip was raised to reveal more of her teeth. In addition, the width of Cela’s mandible was narrowed at the back and its angle made more obtuse. 14 In that final procedure, the ‘strong jaw’ that in surgical discourse marked her as male and in her own narrative marked her as Filipino was removed.
According to Ousterhout, a ‘square jaw’ like the one that Cela had pre-operatively was a distinct sign of male facial structure. He is not the only one who thinks so. The equation of square jaws to maleness is ubiquitous in peer-reviewed surgical papers on FFS (e.g. Altman 2012; Becking et al., 2007; Raffaini et al., 2016; Shams and Motamedi, 2009), and was reliably reproduced by patients who identified their square jaws as ‘problem areas’. Jaw tapering and jaw reduction are commonly deployed in FFS operations as patients aim for the ‘softer’ oval or heart-shaped face they associate with aesthetically desirable femininity.
Because Cela had been reliably recognized as a woman before FFS, I wondered how these invasive procedures that so many other patients said they needed in order to be accepted as women had impacted her life. When I asked if she noticed a change in people’s response to her after surgery, she waved her hand above her head in a wide circle and declared: Oh yeah! Before a lot of people really thought I was attractive, but now they’re like, ‘Wow, you’re really attractive.’ I feel like if 20 guys would hit on me a day [before], it doubled [after surgery]. I have less women friends now, though. I feel like they got more competitive.
Cela explained that part of her increased attractiveness came from the surgical removal of the characteristics that made her distinctively Filipino. [Before surgery] I wasn’t really thinking, ‘Oh, I look like a boy.’ But then after he did the surgery I was thinking, Oh my god, he really took out a lot of the hardness. I think it made me look younger. It made me look more kidlike. So without make-up on I look really young. So I’m like, ‘Oh, it took out years!’
The complex entanglement of aesthetic femininity, claims to morphological femaleness, and ethnic identity was not lost on Ousterhout; he was quick to note that the skull and face are primary sites of ethnic differences. In a presentation at a large trans- health conference, for example, Ousterhout explained that, A Japanese gal and a Chinese guy have differences in their skull and it’s important for me to know these things. They’re both very attractive, beautiful people [referring to a slide image] but there are some things that are different. It’s important for me, if you happen to be Chinese, Japanese, or Black, to understand these differences and preserve them.
But some ‘ethnic aspects’ are framed as simply at odds with normative femininity itself. In such a case, a determination of priorities must be made. This is the case, as Ousterhout explained, with Korean women whose Koreanness makes them atypically masculine. I don’t know if you have any Korean friends, but a lot of Korean women have very square faces. I’ll tell you, they want to get rid of that so fast. They want a classic, tapered lower face. A typical female face. Korean women with big lower jaws are attractive, but they’ve got a very masculine lower face, if you think about it.
In the cases of Barbara’s Greek nose, Beth’s Irish ears, and Cela’s Filipino jaw, ethnicity, like (and as) masculinity, was identified as problematic excess that had literally grown on top of the narrated neutral feminine form within. It was not simply that male features and ‘ethnic’ features were relatively bigger, it was that they were too much. The Greek nose was too prominent, the Irish ears were too wide, and the Filipino jaw was too square to be feminine. While FFS is the only case that I know of in which the excesses of masculinity are an explicitly surgical problem, masculinity is frequently described as excessive, and so are characteristics marked as ‘ethnic’. 15 The conception of the non-white body as one marked by its excesses of anatomy (and of appetite) has a long history. 16
Excess as a surgical problem: the Asian jaw
One way to examine the homology of masculinity and ethnicity as facial excesses is to note the surgical procedures that their removal shares in common. Surgeries performed on facial bones for the express purpose of feminization often target the same parts and characteristics as those that aim to remove or reduce ‘ethnic’ features. Following Cela’s story above, I focus here on surgeries that reduce the ‘Asian jaw’. 17
Though a considerable amount of critical attention has been paid to the steadily growing demand for blepharoplasty (eyelid surgery) among Asian people (primarily women) (Aquino, 2017; Gilman, 1999; Heyes, 2009; Holliday and Elfving-Hwang, 2012; Kaw, 1993; Zane, 1998), relatively little has been paid to the bone reconstruction work performed on the ‘Asian face’. The most invasive of these procedures involves the reduction and/or removal of the ‘wide’ and ‘flared’ mandible responsible for what is described in surgical literature as a distinctly Asian facial squareness. A 2006 plastic surgery article cites, ‘hypertrophy of the mandibular angle’ (an outsized squareness of the jaw) as ‘the most common lower face deformity in Asian women’ (Ying, 2006: 67). 18 ‘The lower face remodeling operation has recently become more popular for patients with mandibular hypertrophy in Asian countries especially in South Korea and China recently. The main reason is that girls in Eastern countries who have an oval face are regarded as pretty’ (Ying, 2006: 67). We might read the authors’ situating of the standard of ‘prettiness’ in ‘girls in Eastern countries’ as simple reportage of patients’ desires, or as a preemptive defense against critiques that these procedures ‘Westernize’ young Asian women. Nonetheless, as demands for certain forms of ‘oval-faced’ prettiness increase, more and more jawbones are being cut out.
Although it has been claimed that ‘mandibular angle reduction’ is ‘unique to Asian plastic surgery’ (Lam, 2005: 320), as I have shown, this procedure is often a key part of facial feminization. The ‘masculine’ characterization of wide jaws crosses over between FFS literature and Asian surgical literature. Plastic surgeon Dr. Samuel Lam notes in relation to the Asian face that, ‘wide, flared mandibles are often deemed masculinizing in appearance’ (2005: 321). 19 He goes on to state, however, that demasculinzation is not the only reason that these ‘wide, flared mandibles’ are reduced. ‘Men are also desirous of reducing both the cheekbones and the mandibular angles, as the thought is that these features render the face wider and thereby flatter and more ethnic in appearance’ (Lam, 2005: 321). Here, as in Cela’s story above, the wide jaw signifies doubly: it is both masculine and ethnic. Its removal, therefore, can enact two kinds of change.
Operating in a binary conceptualization of sex, less masculine means, de facto, more feminine. Through the lens of critical whiteness studies, becoming less ethnic is a means of whitening, regardless of whether its form conforms to or centers a ‘white’ racial ideal. ‘Whiteness’, Ruth Frankenberg writes, ‘comes to self-name…simply through a triumphant “I am not that”’ (1996: 7). Whiteness is a social identity, standpoint, and bodily form consolidated through the refusal of ethnic specificity in favor of a status as unmarked, normal, and natural. In the practice of FFS, binary forms of sexual difference presented as unmarked, normal, and natural, confront the specificity of ethnic features and require a special conversation. Ethnicity and masculinity are defined as such through their exclusion from the animating ideal of demure, soft, oval shaped, straight nosed, and high cheekboned femininity. Constituting the undesirable excess that obscures the feminine ideal, they are targeted for surgical resection. It is crucial to see that when Cela’s jawbone was interpreted as characteristically masculine (by Ousterhout) and distinctively Filipino (by her), and when masculinity and ethnicity are the constitutive outside by which desirable femininity finds its form, then feminization surgery enacts a change in both of these at once.
Conclusion
The first step in FFS, like all reconstructive surgery, is definitional. Surgeons must define the problem in which they will intervene and develop a surgical plan oriented toward remedying that problem. The promise of FFS is that while before surgery (most) patients are recognized by others as male and therefore treated as men or as visibly transgressive trans- women, after surgery they will be recognized as female and therefore be treated as women. In order to enact this change, surgeons assess patients’ faces and stake a claim as to the changes that must be made in order for this new mode of recognition to be enacted. In the process, surgical assessments reify masculinity and the animating fantasy of femininity not as sensibilities or performative effects but as physical structures that can be reliably identified and surgically reproduced.
Through recounting clinical assessments, in this article I have shown that patients’ and surgeons’ understandings of facial sex differences – of what men and woman look like – are complexly entwined with ideas about the physical structures of ‘ethnicity’. When Barbara’s nose was targeted as both Greek and masculine, Beth’s ears as both Irish and masculine, and Cela’s jaw as both Filipino and masculine, features that signaled ‘ethnic’ belonging were also coded as signs of bodily maleness. In the process, the ideal of the desirably feminine face was constricted: only particular faces, unmarked by ethnic specificity, could be seen as transparently female. These bodies, diminutive and unburdened by the excesses of robust maleness and intemperate ethnicity, could be literally carved out from under the bulk of such undesirable bodily characteristics.
The desirability of diminutive forms reflects both a preference for demure and restrained femininity as a ‘good’ surgical outcome, and the ways in which this preference has been written into scientific and medical ideas about the nature of sex difference itself (Fee, 1979; Jordanova, 1993; Russett, 1989; Schiebinger, 1987; Stepan, 1986). The discourse of FFS that is presented in surgical literature, narrated by surgeons, and reproduced by patients is that FFS interventions are based on scientific differences between the faces of males and females. But even while the ideals of sexually binary forms are reproduced, they are constantly hemmed in and revised by forms of difference and variation presented by age and ethnicity. Even after the brief set of accounts reproduced in this article, the claim that female faces have a particular form must be followed by an asterisk: *for exceptions to the normal female form see Black, Chinese, Japanese, Korean, Irish, Greek, and Filipino. Once the specificity and variation represented by all of these exceptions are accounted for, the claim to binary facial sex difference is beleaguered. In FFS clinical practice, just as in its academic beginnings, the faces that were considered transparently female were those that conformed to unmarked ideals of European beauty. When, in practice, FFS self-consciously enacts a patient’s move away from physiognomically identifiable ethnicity in order to achieve an ostensibly neutral femininity, it becomes not only a process of feminizing the face but of whitening it, regardless of whether features associated with ‘white’ racial identity are the express desire of the patient or aim of the surgeon.
Like all forms of surgical sex reassignment, FFS materializes into action and incites into speech a number of contested social categories. Developing a plan to ‘feminize’ a trans- woman’s face, surgeons must answer the question, ‘What does a woman look like?’ In so doing, they fold received ideas about desirable aesthetics and anatomical differences into their understandings of what must be done to accomplish their patients’ goals of being recognized as women. Recognition is a distinctly intersubjective affair, taking place irreducibly between people in a common social milieu. It is in that space, when acts of recognition hang on shared understandings of bodies as things that bear signs of sex, ethnicity, and other forms of belonging and exclusion that surgical practices cut dynamics of power into skin and bone.