Facial Feminization Surgery and The Standards of Care

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only the first part of the problem. Most “soft tissue” surgery is only “medicallynecessary” due to the need to adjust the soft tissues in response changes in theunderlying bone. Many so-called “cosmetic” procedures are routinely performed tocorrect problems created by surgical interventions focused on non-aesthetic issues inother fields of medicine (e.g. removal of cancerous lesions or tumors).The most common objective raised when considering facial feminization surgery,as a part of gender conformation is where to draw the line between modificationsrequired to effect gender perception and those that are simply aesthetic. Although thisdistinction may at first be difficult to approach, a case can be made for making such adistinction after careful thought. Careful consideration of:(1) A procedure’s ability to influence the gender gestalt,(2) The availability of satisfactory non-surgical alternatives,(3) An individuals ability to compensate through diet and exercise and(4) The demand for the procedure in the non-transgender population.Each of these characteristics must all be carefully weighed when determining if agiven surgical procedure is being performed for aesthetic consideration or as part ofgender conformation. The following is a partial list of some of the issues the writerfeels should be examined in this discussion.(1) Modifications to the underlying bony structure of the skull (e.g. brow ridges,mandibular angle, chin height) are essential gender conformation surgeries.The influence of these modifications on the gender gestalt is profound and thesame effects cannot be obtained through any acceptable prosthesis or throughdiet and exercise. In addition, the demand for these procedures is extremelyrare outside the transgender community.(2) Soft tissue modifications (e.g. blepharoplasty, face and neck lifts) are notnecessarily essential gender conformation surgeries when done in isolationHowever, if they are performed in concert with any of the essential genderconformation procedures just described, to compensate for modifications to thesize and position of the underlying bone, they may be practically necessary.(3) Procedures that are commonly employed by the general public to enhanceappearance (e.g. breast augmentation) or change ethnic identity (e.g.rhinoplasty) may greatly augment gender presentation but may not be essentialgender conformation procedures if done in isolation. Such surgeries could beconsidered necessary if they can make a substantial impact upon the gendergestalt however.(4) Some procedures that are not considered essential for gender conformationmay become functionally necessary in conjunction with primary structuralmodifications (e.g. rhinoplasty in conjunction with brow and forehead recontouring,face and neck lift in conjunction with mandible re-contouring).(5) Soft tissue modifications that can be influenced by behavior and/or diet (inconjunction with hormone therapy) might not be considered essential genderconformation surgery although they may be extremely helpful in generating thecorrect gender gestalt (e.g. liposuction of the chin or abdomen).(6) Procedures for which no acceptable means of mitigation exist without surgery(i.e. no prosthesis are available) must be considered critical and medically- 10 -
necessary in the context of gender dysphoria. For example, thinning hair canbe covered with wigs and insufficient breast augmentation can be treated withprosthesis but nothing can change facial bone structure except surgicalintervention.Changes to the underlying bones of the face (e.g. brow, chin, etc.) are typicallyessential gender conformation surgeries while soft tissue modifications are not. Acase can be made however for including soft tissue modifications if they are madenecessary by procedures intended to modify the structure of the underlying bone.Even some modifications of the bone directly may not necessarily be essential genderconformation surgeries (e.g. rhinoplasty) although they may greatly assist ingenerating a female gender gestalt. Almost all of the procedures developed for“cosmetic” purposes in other contexts however may come into play particularly whenmajor structural changes are made to the underlying shape of the skull. An exampleof this is the need for a face and neck lift in concert with extensive modification of themandible.Another impediment to insurance coverage for the “cosmetic” proceduresemployed in transgender medicine is the natural reluctance of the companies to coverprocedures for one group while denying them to others. A perfect example of this isthe obvious need for hair transplants by transgender patients that have developedextensive male pattern baldness. Although hair transplants can be tremendouslyvaluable to individuals with this condition the insurance companies would be extremelyreluctant (possibly with good reason) to cover them only for transgender individuals.Many genetic women also develop thinning hair with age and the writer canunderstand the rational that covering a procedure for one group and not another isultimately untenable. (The writer must confess however that this isn’t one of her issues so she maylack the proper perspective)In general, when a procedure is commonly employed for aesthetic purposes in thegeneral population (e.g. breast augmentation) it reflects a general desire in the publicfor features that are not always created by nature. Many women are unsatisfied withtheir breast size and a large market exists for breast augmentation services for purelyaesthetic reasons. Having large breast is not an automatic requirement for beingperceived as female however particularly when the face and the rest of the body are inagreement. This fact argues against including breast augmentation as a criticalgender conformation surgery. Exceptions do exist however particularly in the casewhere an individual cannot tolerate hormones that would allow natural breastdevelopment. In such cases an argument could be made for considering breastaugmentation as a critical gender conformation surgery in the same fashion thatbreast augmentation is considered “medically necessary” following a mastectomy.Liposuction is another example of a “cosmetic” procedure that can greatly benefittransgender individuals that may not be defensible as a critical gender conformationsurgery. Many transgender individuals develop fat distributions that are characteristicof their natal gender and interfere with presenting the “correct” gender gestalt. But ifliposuction is covered for one group shouldn’t it be covered for everyone? Fatdeposits (particularly under the chin and around the abdomen) can seriously interferewith presenting as “female” and certainly effect how attractive an individual isperceived to be. Men and women store fat differently and only very long-termexposure to cross-gender hormones can significantly influence their distribution.- 11 -
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Facial Feminization Surgery and The Standards of Care

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