Time, facial feminization, and the transgender experience

Time, a precious commodity for all of us, poses extra challenges for transgender people.

Every day they confront the 100 milliseconds it takes a binary mind to form an impression and judge another person: “Is that a man or a woman?”

My trans female patients share their emotional pain about having to wait to begin their journeys to medically transition their gender through hormones and procedures. They typically face years of emotional and physical challenges with gender dysphoria in a world slow to catch up with treatments and understanding. That timeline can be further slowed by patients having to produce referral letters for every part of the transition process — from hormone therapy to initial surgical consultations and revision surgeries.

Transgender people always have existed, but it was only in May 2019 that the World Health Organization stopped calling gender dysphoria a mental illness and redefined it as the “marked and persistent incongruence between an individual’s experienced gender and the assigned sex.”

Perhaps the newness of this shift is why there are so few evidence-based approaches that move transgender patients closer to physical and emotional acceptance by themselves and others. The relative dearth of hard data on gender dysphoria makes it challenging for professionals like me who treat and support transgender patients on their physical and emotional journeys. Our work doesn’t evolve quickly with research-based studies, but does so patient by patient, day by day.

For trans females, one component of transitioning is facial feminization surgery. This collection of procedures, also known as facial gender confirmation surgery, can transform a person’s face — and life. Procedures that reshape the jaw and brow lines, shave the Adam’s apple, and augment the lips are often part of a gender-affirming experience that, over time, helps classify a transgender woman as a woman, even at first glance.

To be sure, facial feminization is not a “cure” for gender dysphoria, but a step in a lifelong process of affirmation and evolution. Evidence indicates that trans female patients report marked improvements in their quality of life and mental health after undergoing it.

Life with facial features that are not aligned with one’s authentic self contributes profoundly to how one feels about oneself, other people, the world around them, and the future. This vulnerability translates into mental health challenges, a high suicide rate, and fatal violence — statistics that lend urgency to patients’ need to transition.

The vulnerabilities transgender women feel before these procedures are often offset by their incredible strength. It takes persistence, insistence, and consistency — and, of course, time — to make the transition happen and achieve peace with who they are and need to be.

Many need that strength to understand that the process of aligning how they feel with how they look isn’t over when surgery ends.

Facial feminization surgeries can initially cause swelling and bruising, and a woman may feel at first that she looks worse, even though she may know she’s not yet experiencing the final result. Later on, some are elated, while others don’t know how they feel about the woman in the mirror. Many experience all of these feelings.

Psychologically speaking, facial feminization surgery is successful when a person has healed both physically and emotionally — when her facial features are no longer at the forefront of her mind and she is able live her daily life with less of a disconnect between her feelings and her looks, and between her looks and others’ perceptions.

This part of her journey should lead to less time questioning or celebrating facial features, and more time simply living.

Helena Roderick, a licensed psychologist, is a senior psychologist for Northwell Health’s Center for Transgender Care; Center for Young Adult, Adolescent, and Pediatric HIV; and Division of Medical Genetics.