When most people think of the medicine of gender reassignment, hormone therapy and genital surgery likely come to mind. In a thoughtfully written feature in The Guardian, journalist Jenny Kleeman describes a new frontier: facial feminization surgery, or FFS. Kleeman introduces readers to trans women who, unsatisfied with — or traumatized by — the way they are perceived physically, visit surgeons who shave jawlines, plump cheeks, lift brow lines, and perform other procedures that can make faces read as more feminine. “I’m not trying to make myself beautiful,” says Sophia Drake, the main subject of the story. “I see testosterone as a poison in my body, a poison that I had to deal with for 20 years. I want to put my face to the way it would have been if testosterone had never been [there].” Her surgeon, Dr. Keith Altman, operated on Drake in October 2019:

There was no more easy chatter between the doctors when Altman returned to the theater to operate on Drake’s brow and forehead. This was the most difficult part of the surgery. It would remove the parts of Drake’s face she thought were most male, the features she hated so much. Altman brushed sterile aqueous iodine over her face and hair, rendering her first rusty red and then yellow. He made an incision into her hairline with a swift, steady hand.

He drew back her skin in either direction from her hairline until it gathered in folds on one side at the tip of her nose, and draped back across her crown on the other. With a tiny steel mallet and a chisel, Altman set to work carefully chipping away her brow bone, before filing it with a tiny drill bit. Then he stopped, and everyone in theatre craned in to see the difference.

When he was satisfied with the result, Altman changed his gloves and turned his attention to her forehead. The MRI on the lightbox showed Drake had a large sinus cavity with a thin wall; the challenge was to saw the bone down without perforating the sinus, and the best way to do this was to remove part of her forehead entirely. Altman drew a 5cm by 3cm rectangle on to her skull with marker pen. He sliced into it with another fine tool, then prized out the section of bone. He held it in his hand as he filed it back, turning a flat plane into a gentle curve. When he put it back in place, he pulled the skin over it, tilting his head to the side to check his work. Finally, the piece of forehead was fixed back in the skull with two 4mm titanium plates, which his trainee, Maini, secured using a tiny screwdriver. Drake’s skin was smoothed back for a last time. “Good,” Altman nodded.

As Kleeman details, FFS raises challenging questions about privilege and beauty standards. The surgery is expensive and not covered by the National Health Service in most of the United Kingdom. According to Juno Roche, author of Trans Power, FFS contributes “a kind of two-tier system where, on the whole, the most successful trans people are beautiful people that pass. People who are proud to be trans, and those people who can’t afford the surgery, fall into a separate category. That’s most people. And we have to create safety for everyone.” Then again, Roche adds, “Trans people deserve an easy life. This is a tough gig.”

For Drake, the results of FFS were life-changing. Kleeman interviewed her two months into post-surgery:

The change was almost imperceptible to me, at first. But I could soon detect a new poise: her face seemed narrower, and strangely her shoulders did, too. Her dimples were more prominent, her eyes looked brighter and more expressive. There was a faint, pale pink sliver of a scar along her hairline, mostly covered by the dark roots of her fringe.

“It was just enough, without being too much,” she told me. “The hairline frames my face better. I find that my eyes aren’t sunken, they’re further out. I feel that I’ve got a lot more expression in my eyebrows now. Other people spot this”—she cupped her hands around her jaw—”more than I do. But when I go back and look at old pictures, I see a massive difference.”

The biggest change was in Drake’s demeanor. She no longer sat with her arms across her chest or played with her jewelry. She was open, at ease, comfortable.

“It’s made me so much happier. Calmer. I can sit and relax in ways I’m not sure I’ve ever been able to,” she said. “I don’t walk around any more worrying that people are looking at me.”

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