Rachel is about to spend a considerable amount of money on plastic surgery. Her objective is not to resemble a Kardashian or to look 10 years younger. She fantasizes about walking into a store in jeans and a T-shirt and having the clerk ask, "Can I help you, Miss?"
Rachel is just one trans- woman profiled by Eric Plemons in his new book, "The Look of a Woman: Facial Feminization Surgery and the Aims of Trans- Medicine," published by Duke University Press.
Plemons is a medical anthropologist in the University of Arizona School of Anthropology and a core faculty member in the UA’s groundbreaking Transgender Studies Initiative.
"The Look of a Woman," the first book-length ethnography of trans- medical practice, explores how changing ideas about sex, gender and transgender are shaping the practice of trans- medicine in the U.S.
In the book, Plemons argues that as ideas shift about the kind of thing that sex is, so do the interventions required to change it. Early surgical procedures that aimed to change a person's sex focused on the genitals as the site of a body's maleness or femaleness.
"Now we think of sex as something that we give to each other," Plemons said. With this model, how people see you and treat you determines your sex. Sex is a product of social recognition.
Susan Stryker, an associate professor in the UA Department of Gender and Women's Studies and a pioneer in transgender studies, said the book "is a readable, well-argued and deeply informed account of how what counts as 'sex' has shifted from genitals to faces over the last few decades."
Once Seen as Auxiliary
Developed in the mid-1980s, facial feminization surgery, or FFS, is a set of bone and soft-tissue reconstructive procedures intended to feminize the faces of trans- women. Once considered an auxiliary procedure in support of the "real" change of sex enacted by genital surgery, now patients who undergo FFS and the surgeons who perform it assert that facial feminization surgery transforms a patient's sex.
"You don't walk down the street looking in everyone's pants to decide what sex they are," one surgeon explained. "You look at their face."
Plemons mentions Krista, covered in bandages at a three-day postoperative exam, excited because no one stared at her on the bus ride over. Prior to the surgery, Krista was often seen — and treated — as a male who was trying and failing to look female.
"It struck me forcibly that of course everyone was looking at her, because she was so visibly injured," Plemons said. "But she was then just another woman going to a plastic surgeon. That intervention transformed her from one kind of a person to another kind of person. It changes your social identity."
Only a small group of surgeons specializes in facial feminization surgery. Plemons gained entry into the surgical practice of Dr. Douglas Ousterhout, who not only developed the FFS procedure but was one of its most prolific practitioners. By the time he retired in 2014, Ousterhout had performed nearly 1,700 FFS operations — more than any surgeon in the world. Plemons also observed in the office of Dr. Joel Beck, who was working to grow his FFS practice.
Plemons acknowledges the importance of his being a trans- man to this access.
"It would be difficult to overestimate the role that my being a trans- man has played in this research," he said. "It has shaped how the project was conceived as well as the kinds of data I was able to collect. This acknowledgment is not meant to flatten or trivialize significant differences between and among people who identify themselves as trans-."
Plemons started the research in 2010 and spent a year observing the practices of Ousterhout and Beck, including watching about 100 hours of surgery. He interviewed six other surgeons and attended surgical workshops. He interviewed 35 patients in-depth and observed the appointments of many others, following them from consultation to postsurgery recovery.
In the book chapter "Cutting as Caring," Plemons places the relationship between surgeon and patient in the context of the historically awful medical treatment that trans- patients have received. Stories of expensive, dangerous back-room medical interventions for trans- women are not new.
"Trans- people have experienced really bad medical care: They are denied care, they are victims of violence, they are forced to undergo procedures they don't want, they are forced to teach their doctors about their care. This results in bad outcomes," Plemons said.
Plemons uses the term "restitutive intimacy" when describing FFS. The surgery is presented as an act of compassion and generosity, framed as a response to the mistreatments of the past. Of course, these surgeons are rewarded quite well financially, a fact that critics will point out. Many patients, even knowing the steep costs, respond with gratitude and loyalty.
"It is part of their practice. The doctors say things like, 'We want you to be the person you have always wanted to be. Sweetheart, you are going to be beautiful.' The patients are looking for that kind of language, because why wouldn't they?" Plemons said.
Plemons said that some people in the trans- community are critical of surgeons and FFS surgery, viewing the surgeons as opportunists preying on trans- women's desire for social acceptance.
"It is not my job to criticize these surgeons or these patients," Plemons said. "It is my job to engage generously with all of them to make the best sense I can out of an extremely controversial, emotionally intense, economically complicated, historically contested practice."
Criticisms of FFS
Plemons spoke to several critics of FFS in the trans- community when conducting research for the book. Some believe that FFS furthers the gender binary and works against efforts that leverage visibility as a path toward political recognition of trans- people as a collective. Some believe that trans- women should not undergo surgery "to make themselves palatable to those whose definitions of women excluded them." They should resist the notion that trans- women's ability to be accepted in the world depends on how well they can "reproduce the narrow confines of normative femininity."
"The conditions that make one recognizable as a woman are actually quite strict," Plemons said.
Ousterhout has tried to market a comparable surgery to trans- men, with little interest. One reason for this, Plemons said, is that society accepts a broader range of "plausible male faces," especially if a trans- man can grow facial hair.
And then there are issues of money. Even more expensive than genital reconstruction, and rarely covered by insurance, FFS is not an option for many trans- women. Plemons said that Ousterhout’s patients — who traveled from all over the world to see him — were "overwhelmingly white and unusually resourced."
"Critics will say that trans- women need a political space to be trans- women and still get rights and respect," Plemons said. "Individually buying your way out of social exclusion and violence does not solve the bigger problem."
Plemons is currently investigating how U.S. institutions are responding to a growing demand for trans- health care, as well as how trans- surgical outcomes are studied and clinically assessed.
He is pleased with the timing of the book's publication, because the World Professional Association for Transgender Health is currently reexamining facial feminization surgery.
"In order to decide what good trans- medicine is, we have to ask the question, 'What are we trying to do?'" Plemons said. "And I think this book offers an insight into what trans- medicine is trying to do. I hope the book, or at least the questions I am trying to set up, can provoke a conversation that is useful."