The Look of a Woman: Facial Feminization Surgery and the Aims of Trans Medicine

The Look of a Woman: Facial Feminization Surgery and the Aims of Trans Medicine. Eric Plemons. Durham: Duke University Press, 2017, 208 pp.

In 1983, a San Francisco-based cranio-maxillofacial surgeon was approached by a colleague with an interesting problem. The question was how to help patients who had recently undergone male-to-female transsexual surgery on their genitals, but who continued to feel dissatisfied with their transformation because their faces still looked male. In the years that followed, Douglas Ousterhout became the most important and well-regarded practitioner of facial feminization surgery, an intervention that many trans women have come to regard as essential to achieving the body and face that would allow them to finally become themselves.

The ethnographic core of Eric Plemons’s fascinating new book, The Look of a Woman: Facial Feminization Surgery and the Aims of Trans Medicine, is the year Plemons spent working in Dr. Ousterhout’s clinic. Over the course of that year, Plemons concluded that in addition to honing a truly innovative surgical practice, Ousterhout was also working from and creating an implicit and potentially influential theory of gender identity.

The Look of a Woman is a new and important examination of the world of trans medicine, particularly the question of gendered identity, facial physiognomy, and most importantly the face-to-face determination of sex. This excellent and enriching engagement with the field of cosmetic surgery studies and trans studies shows us how the conviction that “I am a man or woman when I am recognized as a man or woman” becomes the essence of the social selfhood we all seek.

That said, the drive for recognition, as Plemons allows, can be “productive and not always affirmative” (p. 15). This is an important caveat, especially in his historical chapters, which show how the movement of trans medicine from university to private clinics since the 1970s paved the way for a contemporary empowerment movement in which patients are no longer being “researched” as people born into the “wrong body” but instead are consumers engaging in trans medicine as a means of self-actualization. What this take masks over, however, is a deep history of the dependence of trans science on understandings of gender and even racial identity borrowed wholesale from the field of physical anthropology. Often, trans science did this borrowing without acknowledging or even realizing the troubling history of racial and gender stereotyping that physical anthropology depended on and disseminated in its early days. In this regard, it would have been enlightening to see Plemons refer to the origins of physical anthropology in physiognomy and its attendant classification of humans into moral and intelligence-rated hierarchies, beginning with the work of the Swiss physiognmist Johann Casper Lavater, though the criminal taxonomies of Cesare Lombroso, and continuing through to the Nazi regime’s eugenic theories of the early to mid-20th century.

Plemons is more fully present when it comes to his analysis of the importation of gender norms in the practice of facial feminization surgery. As he notes, “Feminine is a term in which biological femaleness and aesthetic desirability collapse” (p. 96). Ousterhout’s goal of creating faces that would satisfy the gender identifications of his patients would in effect never be free of the aesthetic judgments that determine which kinds of looks are more feminine and hence more desirable than others. This idea and critique opens the door to the important and at this point classic debate within gender philosophy of the “drag” that the body’s materiality imparts on the discursive flexibility of gender identifications. This flexibility was theorized, and in some ways advocated most influentially, by Judith Butler in the 1990s. To put it in another way, if facial feminization is, as implied by the nominalized verbal form of the term, a movement toward a goal, is it not likely to carry within it an always unsatisfied and even unsatisfiable kernel, a reminder that the identity one wishes to regain is an identity that one didn’t have at birth? While Plemons concedes the possibility that trans theorists and activists have overdetermined the “theatrical” nature of Butler’s gender performativity, installing in it a kind of willful agency over one’s gender identity that Butler herself has argued was never there, it remains the case that he cleaves to a line in the debate that situates the trans body as a site of resistance to attempts to use it exclusively as a marker of gender fluidity. Here I would simply note that, indeed, both “sides” are right, since neither is or was arguing for a facilely volitional gender identity, but rather an understanding of gender identity as a sedimented materialization, to use Butler’s later term, embodying years and even generations of gendered practices and behaviors.

It is especially refreshing and powerful that Plemons incorporates his own transgender identity as the situated perspective from which he writes. He thus reveals a personal position vis-à-vis his subject matter, pointing out that “I am an ethnographer of trans- surgical practice not because surgery defines us as trans- people but because it is so very important to so many of our lives” (p. 24). Particularly incisive is his habit of intercutting scenes and interviews with theoretical discussions, a technique that not only enlivens the theory but also illuminates descriptions that might otherwise lack an overall argumentative coherence. I like these places of self-reflection and self-reveal very much, and only wish Plemons would have done this even more persistently throughout. The lived experience is a place from which completely different insights can be drawn about the emotional impact of the desire to pass in face-to-face social situations. I recall vividly, for instance, his analysis of Candace’s face and the problem she had with the fact that no make-up would hide the fact she was a man. In this instance, I almost wish he could have lingered more, and perhaps added layers of psychological analysis detailing how this felt to Candace, or even to himself, since we know his interest in the subject stems from his own experiences as a trans man—even if the challenges of feminization are, as he points out, very specific to trans women. Indeed, while it may be relatively untraditional in academic writing to bring the personal experience so strongly into the examination, in this case I think even more of it would have benefited the book because of the opportunity it creates to understand from a comparative perspective the underlying consequences of “feminization” versus “masculinization,” and indeed to see them as vectors of desire rather than stable categories.

This writing from lived experience reminded me of a recent pamphlet from my son’s (progressive) school, in which the various preparatory events for the graduating seniors included the items “Lunch for those seniors who identified/identify as male,” and “Dinner for those seniors who identified/identify as female.” The plaintive beauty of an attempt to be so inclusive to all also reveals the paradox that is so achingly present in the subjects of Plemons’s research: the very technologies and epistemologies that permit the “misembodied” to find themselves again can, if not treated with the utmost delicacy and care, undermine the stability, even reality, of the identities they feel so strongly, and desire so powerfully to regain.