The Look of a Woman: Facial Feminization Surgery and the Aims of Trans- Medicine
208
The Look of a Woman: Facial Feminization Surgery and the Aims of Trans- Medicine
208eBook
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Product Details
| ISBN-13: | 9780822372707 |
|---|---|
| Publisher: | Duke University Press |
| Publication date: | 07/27/2017 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 208 |
| File size: | 2 MB |
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CHAPTER 1
On Origins
The classification of individuals into dichotomous sex categories inevitably involves cultural work made possible by a history of definitional acts.
— STEVEN EPSTEIN, Inclusion, 2007
BEGINNING BEFORE THE BEGINNING
Douglas Ousterhout had just completed a general surgery residency at the University of Michigan when, in 1970, he packed up his life in Ann Arbor and moved to Palo Alto to begin a plastic surgery residency at Stanford University. "Before I started at Stanford," he explained, "I told them I didn't want to work with the gender program. I had heard what Don Laub was doing there, and I wasn't interested in working with transsexual patients." In the early 1970s virtually every plastic surgeon in the United States was aware of the new programs being established at universities across the country that were offering surgical services to a growing group of patients diagnosed as transsexual.
The first of these clinics opened at Johns Hopkins University in 1966, the year after Ousterhout graduated from medical school. Largely funded by private individual and institutional grants from the Erickson Educational Foundation, the Hopkins clinic served as an early model for the development of similar university-based clinics across North America, ushering in a brief period in the mid-1960s to late 1970s that the historian Susan Stryker (2008:93) has called "the 'Big Science' period of transgender history." Despite ongoing controversies among psychologists and medical doctors over what kinds of medical and surgical treatments should be offered to people newly understood to be suffering from transsexualism or gender dysphoria — if indeed any such treatments should be offered at all (Reay 2014) — at least a dozen university-based gender clinics were operating in the United States by 1979 (Restack 1979). Stanford University's Gender Dysphoria Program (GDP) opened in 1968 under the direction of Dr. Donald Laub, a plastic surgeon, and would prove to be one of the most influential programs in the country.
During his time as a plastic surgery resident at Stanford, Ousterhout's request to avoid working with Laub's GDP patients was granted, for the most part. He was never trained in the techniques used in genital sex-reassignment procedures — the operations most commonly associated with transsexual surgical interventions and for which Laub would become quite well known — but Ousterhout did see GDP patients in postoperative rounds and provided postsurgical care appropriate to his status as a resident. "I didn't have any real reason not to like them," he explained of the GDP patients. "I think that like most people at the time, I just didn't know anything about transsexuals, and I didn't really want to know." After leaving Stanford, Ousterhout turned his attention to craniofacial reconstructive surgery and thought his encounters with transsexual patients were behind him. But his connection to Stanford plastic surgery and the rapidly changing landscape of trans- medicine in the United States would bring trans- patients to his attention again nearly a decade later.
As quickly as they had been established, American gender clinics began to close down in the late 1970s. Despite its central role in the institutionalization of trans- medicine and the many technical innovations produced by its surgeons, the Stanford Gender Dysphoria Program closed its doors in 1980, when, like many chief surgeons in gender clinics around the country, Laub left academic medicine for private practice. (He continued to operate on trans- people as patients of Gender Dysphoria Program, Inc., now a private clinic located across the street from Stanford's campus.)
In 1982, two years after the Stanford program severed relations with the university, a former patient named Candace returned to see the surgeon who had performed her genital sex-reassignment surgery (GSRS) some years before. Despite the profound change that GSRS had enacted in her body and sense of self, Candace found that its transformative power was limited to her body alone. Though the fact of her restructured genitalia constituted her as a woman medically and legally, socially it made no change in her life at all. Like many women Candace had gone to great lengths to cultivate a desirably feminine body: she wore her hair long and well styled, and she made strategic choices in clothing and makeup. She had begun what would be a lifelong regimen of hormonal therapy, undergone electrolysis to remove her facial and body hair, and devoted considerable time to retraining her voice and comportment. Despite her best efforts, however, others still saw and reacted to her not as the woman she knew she was but as a man who was trying — but failing — to look like a woman. She endured insults and stares and felt the weight of disdain directed at those whose bodily presentations deviate from the norm. The fact of her new female genitalia — the bodily metonym of sex difference whose transformation is often believed to instantiate if not to define "sex change"— was secreted away behind the bounds of propriety in social life: no one knew it was there. But they did see her face. It was clear to Candace that her face was the problem. She had a man's face. No amount of makeup or decoration could hide it. She returned to her plastic surgeon, wondering if anything could be done. Her surgeon turned to Ousterhout.
By that time Ousterhout had established himself as a distinguished cranio-maxillofacial surgeon. After leaving Stanford years before, he completed a prestigious fellowship with the renowned craniofacial surgeon Paul Tessier in Paris and then returned to California, where he helped to found the Center for Craniofacial Anomalies at the University of California, San Francisco, Medical Center. Prior to Candace's request, Ousterhout had never thought about skulls as being male or female, masculine or feminine. "Here I had been operating at UCSFfor several years," Ousterhout explained, "and I had never thought about the differences between a boy's and a girl's skull." Ousterhout's work as a cranio-maxillofacial surgeon had been guided by the directive to make pathologically abnormal skulls and faces into "normal" ones. And up to that point "normal" had not been a sexed or gendered category.
Still ambivalent about working with transsexual patients, Ousterhout was intrigued by Candace's problem and drawn to the technical challenge her case presented. Treating her offered him the chance to do something new. Whatever technical skills might be necessary, the first step was a definitional one: at that point, as a surgical category, "the female face" did not yet exist.
This chapter begins with the story of how facial feminization surgery was developed in the early 1980s and ends with an accounting of how Ousterhout's FFS practice looked when I began working in his office in 2010. In the early years Ousterhout considered facial surgery a cosmetic procedure that was auxiliary to the transsexual patient's primary treatment of genital surgery: genital surgery changed her sex; facial surgery made her appear more congruously female. Over time, however, his opinion about the kind of change FFS enacted began to shift. In conversation with his patients, more and more of whom sought FFS either before GSRS or in lieu of it, Ousterhout began to understand FFSnot as supplementary to the change of sex effected by genital surgery but as enacting a change of sex in and of itself. It was when others recognized a trans- woman as a woman that she truly became one; the shape of her genitals was simply irrelevant most of the time. By the mid-1990s Ousterhout had come to understand facial reconstruction surgery as enabling a much more meaningful transformation in the lives of trans- women than any other surgical procedure could. Not a private nor a genital affair,FFS was both influenced by and provided a medical model for thinking sex/gender as an effect of social exchange and intersubjective recognition, a shift that would ultimately offer an alternative way to interpret the goal of transition and the place of medicine within it.
HOW TO MAKE A FEMININE FACE, IN THREE STEPS
Some three decades after he'd originally set out to devise a series of procedures to make Candace's male face into a female face, Ousterhout told me that his research had involved three main steps. First, he needed to determine where sex was located in the face — which bone and soft tissue structures marked meaningful differences between male and female — in order to know precisely where to intervene. Finding no help from medical sources for which a wide variety of anatomical forms fall into the unsexed category of "normal," he turned to a tradition of scholarship that had long been interested in what skull variations might demonstrate about human difference: physical anthropology. He found cues to sex distinction in the now highly contested methods by which early twentieth-century physical and forensic anthropologists assigned sex to human remains. Second, he needed to ascertain how to quantify the sex differences anthropologists had identified so that he could surgically reproduce them. He found these quantifications in an early twentieth-century orthodontic study conducted on schoolchildren at the University of Michigan. Third, he needed to determine how to turn this information on sites and forms of difference into a feasible surgical plan. For this practical application he visited a collection of skulls amassed in the early twentieth century and housed at the Dugoni School of Dentistry at the University of the Pacific in San Francisco. After this three-step research was complete, Ousterhout worked across and knitted relations between these three very different types of source material in order to produce two things: a definition of a distinctly female face and a set of surgical procedures he could use to produce it. These procedures would become known as facial feminization surgery.
Defining the term feminine that lies at the heart of the project of facial feminization surgery is no easy task. Sometimes a biological category anchored to the genes and hormones of the female, and sometimes an aesthetic category defined by desirable beauty, feminine is a term in which biological femaleness and aesthetic desirability collapse. Female, feminine, and femininity are terms whose definitions are deeply tied to racial notions of the normal and ideal body, the normal and ideal woman. The story of facial feminization surgery is entwined in these powerful methodological, political, and epistemological histories. Like all transmedicine, the practice of FFS materializes into action and incites into speech contested ideas about sexed bodies; it defines sexual difference as a condition of devising strategies to produce it. When conceptualizations of sex and gender change, so do the medical interventions intended to respond to them.
Step One: Physical Anthropology
When he began to search for the craniofacial morphology of sexual difference, Ousterhout joined a long and contentious legacy of American research that has sought to understand the relationship between skeletal features and forms of social difference. The field of physical anthropology was established in the United States in the first decades of the twentieth century. Reflecting contemporary social and political anxieties, early research on racial difference and the place of women in economic and political life was guided by the idea that social differences between groups were the result of — and could therefore be observed in — physical differences in the bodies of group members. Most often associated with naturalist studies of race in the eighteenth and nineteenth centuries, measurements of the skull and face remained a primary focus of research until the methods of what is now often called "scientific racism" fell out of favor following World War II. Still the influence of this scholarship lives on in many forms, including the claims to sexual difference that it helped to produce and the material collections of skeletal matter on which those claims are based (Blakey 1987; Fabian 2010; Gould 1981; Haraway 1989; Lindqvist 1997; Van Wyhe 2004).
Ousterhout turned to physical anthropology because anatomical and medical atlases — the typical resources of the reconstructive surgeon — do not identify distinctly male and female skeletal forms. So long as they enable people to function healthfully, doctors rarely pay attention to the ways bones vary in size and shape from person to person. Physical and forensic anthropologists, however, pay a great deal of attention to this kind of variation. These practitioners use differences in the size, shape, and quality of particular bones to distinguish a number of characteristics about an individual, including that individual's sex — a category that until quite recently in archaeological scholarship had only two options: male or female. Skulls have been central to studies of skeletal sex distinction.
There is no such thing as a skull that exhibits sex characteristics alone. Though researchers may treat categories of interest such as sex, age, nutrition, race, or population group as distinct variables, in fact these aspects of any given body are inextricably entangled; they form and inform each other. It is not possible to ascertain the sex of a given skull without also considering the age at which the person died, for example, because the age of a skeleton largely determines the extent to which sex-differentiating characteristics are present (Meindl et al. 1985). Similarly, placing a skull into a sex category also requires an understanding of the race or population group to which a skull belongs. In short, sex, like race and age, is a contingent category; its expression is never independent of other biological and environmental factors that influence skeletal characteristics (Gere 1999; Joyce 2005). When producing an ostensibly neutral model of a female or male skull, characteristics that might exhibit such things as race and age are not gone; their irrelevance to the didactic aim of the model only makes them seem to disappear.
To make matters even more complex, human male and female bodies "share about 95% of the total range of [physical] variation," meaning that male and female bodies are far more alike than different and that nearly every bodily characteristic found in an individual placed in one sex category can be found in an individual placed in another (St. Hoyme and Iscan 1989:59). Though anthropological scholarship has continually stressed these complexities and contingencies, unfamiliar readers committed to and invested in the idea that human bodies come in mutually exclusive and sexually dimorphic forms don't always contend with their intricacies. Taking the project of transsexual transition seriously — that the process facilitates the transformation of one sexed body to the other — Ousterhout was looking for a distinctively female skull, and in his reading early twentieth-century physical anthropology supplied it.
As Siobhan Somerville (2000) and others have argued, early twentieth-century scholarship on racial and sexual classification considered the white body the norm from which racially marked bodies diverged. This foundational assumption animated the early anthropological sources that Ousterhout consulted and, as I describe in the next section, also populated the data from which his FFS figures emerged. (For a more detailed account of this research, see Plemons 2014.) Though not intentionally so, the model "female skull" that resulted from Ousterhout's research was a distinctly northern European skull, bearing the historical legacy and practical burdens of its creation. A key part of that historical legacy is the refusal that it is historical at all. Instead a very simple story of human sexual difference emerged: it is an anthropological fact that males and females look different from each other.
To name the conditions under which particular claims to difference emerge and are supported is not to deny that differences exist. It is instead to name those differences as products of human interventions rather than natural occurrences that humans simply record (Fausto-Sterling 2000). As Ousterhout's story of face-to-face sex determination suggests — and as most of our daily experiences attest — most of the time we are able to look at a person's face and place them into a sex category almost immediately. According to one American study, viewers correctly assess the facial sex of those they meet 96 percent of the time (Andreu and Mollineda 2008). These assessments are not based on universal and ahistorical biological truths about human bodies; they depend on who is looking and what they're looking for. For Candace, a middle-aged white person living in San Francisco, the unfortunate reality was that the people around whom she lived and worked recognized her as a man even when she felt she was a woman. It was this persistent and unwelcome recognition that brought her to Ousterhout's office.
(Continues…)
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Table of Contents
Acknowledgments ixIntroduction 1
1. On Origins 21
Interlude. The Procedures 39
2. Femininity in the Clinic 43
Interlude. Celebrate! 67
3. Cutting as Caring 71
4. Recognition and Refusal 89
Interlude. My Adam's Apple 109
5. The Operating Room 113
6. And After 135
Conclusion 151
Notes 157
References 169
Index 185
What People are Saying About This
"In the early 1990s, Judith Butler theorized a new performative model of sex/gender; now Eric Plemons provides us with an exemplary ethnographic analysis of how that discursive model materialized as surgical practice, transforming medical treatment for transfeminine people along the way. It 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. It is of interest not only to members of trans* communities, but to anyone working in the history or anthropology of medicine, and to scholars of gender, sexuality, and embodiment more generally."
"What does a woman look like? This fascinating ethnography of facial feminization surgery made me see that question in a new light. There is much here that troubles social constructionist accounts of gender. Sex inheres in skulls and jaws. By reshaping them in line with sex-specific population norms, surgeons help their patients to reach the ultimate frontier in 'passing' as women. But equally Eric Plemons shows that transient beauty ideals and different surgical practices guide sex transformation. A rigorous analysis that is also a sensitive portrayal of the embodied experiences of trans- people."