What is facial feminization surgery? For trans women, ‘it’s an issue of personal safety,’ say doctors

Trans influencer Dylan Mulvaney gave a whole new meaning to “gender reveal” recently, when the “Days of Girlhood” TikTok series creator posted a “face reveal” after having undergone facial feminization surgery (FFS). For many followers, this marked the first time they’d ever heard of the procedure, prompting a discussion that swiftly made FFS a trending topic on social media, with more than 800 million mentions of the term on TikTok alone.

“I’m so happy, and it’s still me, it's just a little bit softer of a version,” Mulvaney, freshly healed from surgery, told her 10.6 million TikTok followers in a video that’s been viewed over 22 million times. “I just hope that all trans and nonbinary people can get the gender-affirming resources that they need because this is life-changing and sometimes life-saving.”

Indeed, doctors who specialize in the procedure say that, above all forms of gender-affirming care — comprised of a wide spectrum of health care services for trans people — facial transformation surgeries can be paramount in an individual’s transition journey.

But why is it so important? And what does such surgery entail?

What facial feminization surgery is, and why it’s a ‘safety issue’ for many

As defined by John Hopkins Medicine, facial feminization surgery (FFS) is “a series of procedures that can reshape the face and its features to achieve a more feminine appearance,” in the same way facial masculinization surgery (FMS) can help trans men (those born biologically female) achieve a more masculine appearance.

Such services can, but don’t always, include surgical interventions to reshape the nose, forehead, jaw, chin, eyelids and brow, as well as the hairline and Adam’s apple (a procedure known as a tracheal shave). Some might opt for various nonsurgical procedures to achieve a desired feminine appearance — such as hair removal, cosmetic fillers, botulinum toxin, fat grafting and liposuction.

FFS (like FMS) is only one possible facet of gender-affirming care, a wide spectrum of hormonal, surgical and/or mental health services tailored to the needs of a trans or gender-nonconforming individual as they move through transition.

For many trans women, the goal of facial feminization surgery is to treat, or limit, the effects of gender dysphoria, which, according to the American Psychiatric Association, is a diagnosis given to trans individuals experiencing “psychological distress that results from an incongruence between one's sex assigned at birth," based on external genitalia, "and one's gender identity," meaning the psychological sense of one's gender.

FFS serves an even larger role when it comes to personal safety. Dr. Fan Liang, medical director of the Johns Hopkins Center for Transgender Health, tells Yahoo Life that facial feminization surgeries can be vital in helping trans people feel safe when presenting in public.

“At its most basic form, it's an issue of personal safety,” Liang says. “Trans women are harassed and abused all the time, and outed in really traumatic ways. And the face is obviously the first thing that one presents when interacting with a stranger, or even somebody that you are familiar with, like a family member or co-worker.”

Dr. Michelle Forcier, a clinician at Folx Health, the first digital healthcare service provider designed by and for the medical needs of LGBTQ people, tells Yahoo Life that facial surgeries offer trans people assurance that "they can be viewed through others' eyes as their gender identity" and not "socially 'clocked' as transgender," making them feel "safer" to express themselves more freely in public.

The concern is not unwarranted. According to a June 2022 report from the Williams Institute, 1.6 million Americans ages 13 and up identify as transgender, and are four times more likely to experience violent crimes than cisgender people (those whose gender identify aligns with their biological sex). The Human Rights Campaign, the country’s largest LGBTQ advocacy organization, reported at least 40 fatal hate crime attacks against trans people in 2022.

These statistics are increasing, notes a January report from the Center of American Progress, and have fueled high levels of social anxiety among trans people. According to data, 90% of transgender or nonbinary people reported taking at least one action to avoid experiencing discrimination — such as avoiding public places, travel destinations, places of worship, hospitals, family gatherings and office spaces. Further, 57% reported that they wanted to see a therapist or mental health professional in the past year but could not afford to do so.

For trans people experiencing debilitating social anxiety, for which hormonal therapies “simply aren’t enough,” Liang says facial transformation care can be a huge relief.

“The dysphoria frequently stems from the face, and until that dysphoria is addressed, it's very difficult for patients to really feel confident going out in public and feel confident about living their life without a constant nagging feeling that they're really not presenting a body that they identify with or feel comfortable in,” says Liang. “I've had so many patients who come to me [post-surgery] and say things like, ‘I didn't even recognize how much elation I would feel after the facial feminization, like, this huge weight has been lifted off my shoulders.’”

“Even though there was awareness that facial dysphoria contributed to the overall dysphoria, it really is transformative and life-changing to have the facial features be addressed in an affirming way,” she adds.

Misconceptions and health coverage barriers

Quite possibly the biggest misconception about FFS, says Liang, is the idea that facial feminization or facial masculinization surgeries are “cosmetic,” when, in fact, for many trans people, they are an intrinsic part of their healthcare.

“They're absolutely not cosmetic surgeries, these are medically necessary surgeries,” Liang explains. “There’s a very clear distinction between facial feminization surgeries and cosmetic surgeries for facial rejuvenation and for ‘turning back the clock,’ age-wise.”

For many transgender adults, gender-affirming care such as FFS offers one of the most vital steps toward living full lives, as supported by many leading healthcare organizations such as the American Psychiatric Association, the American Nurses Association and the World Medical Association.

External pressures from medical organizations and leading LGBTQ advocacy groups is one reason why virtually all major insurance companies — including Aetna, Cigna and Blue Cross Blue Shield — have recognized that trans-related medical care is medically necessary, and have written policies describing their criteria for when their plans will cover it.

As noted by the Trans Health Project, a movement aiming to achieve health care equity in the trans population, insurance coverage is largely dependent on a person’s individual health plan — and not all plans fit the criteria for full, or even partial, coverage.

That's evident in a Center of American Progress report that showed that trans people routinely encountered health insurance barriers in 2022, such as “limited coverage for different types of gender-affirming care and network inadequacies in health plans.” For example, over one-third of trans and nonbinary people reported that their health insurance company covers “only some kinds of gender-affirming care,” excluding coverage for other kinds of care such as top surgery or facial feminization.

Additionally, per the report, more than one in four transgender or nonbinary respondents said that in the past year, a health insurance company covered gender-affirming surgery but had no surgery providers in its network, further highlighting network inadequacies in coverage plans. Making things even more complicated, 24% reported that in the past year, their health insurance company would not change their records to reflect their current name or gender.

Still, despite the complicated battle surrounding coverage, Forcier says the situation is far superior to that of decades past.

“As long as 10 to 15 years ago, most insurances did not cover any gender surgery,” she says. “[Trans people] were told it was ‘cosmetic’ and they had to scrape together tens of thousands of dollars to get this important medical care.”

Unlike many medical interventions, Forcier notes, FFS, while it sounds costly, in the end reduces dysphoria and "improve quality of life" but might also "reduce costs of emergency medical services for transphobic assault and hate crimes or inpatient psychiatric services for anxiety, depression, and suicide.”

“It is not about a perfect nose or face lift for [combatting aging],” she implores. “It is about having a face that looks back to them and out to the world that reflects their true gender identity. It is about reducing dysphoria and all the harms we know that brings. It is about creating opportunities for safety in a world where transgender women are at some of the highest risk for both hate crimes and death by a hate crime.”

The importance of visibility

Raising awareness about the misconceptions of facial feminization surgery — while celebrating people who are educating the public about the nuances of gender transition, including Mulvaney and others like Drag Race’s Gigi Goode (seen above), Billie Lee and, years earlier, Gigi Gorgeous as well as Hari Nef, who live-tweeted about her trachial shave — is vital to advancing healthcare equity for trans people, says Liang.

“Everybody's gender journey is different. The simplest way of describing it is that patients say they feel like they're ‘trapped in the wrong body.’ You can imagine how traumatic that would be, feeling like your body is not aligned with your identity,” she says. “So, the surgeries and the other interventions are a way to sort of allow for that alignment and identity.”

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