Facial Feminization Considerations for the Transgender Patient

Abstract

Facial feminization is a desire expressed by certain individuals who identify beyond the gender binary seeking to align their physical appearance and the gender with which they identify. Although there are many ways to achieve a more feminine facial appearance, several factors influence routes that patients choose. This Viewpoint explores the considerations of physicians aiming to advocate for transgender patients, and “leverage expertise to promote protection of gender-affirming care”1 through medical and surgical interventions to achieve facial feminization. Due to gaps in literature, this Viewpoint further addresses some of the clinical, ethical, and aesthetic issues that require support of physicians. Injectable fillers remain a popular option for achieving a more feminine look, as they are quick and reversible and valued among patients less inclined toward irreversible procedures.2 Additionally, using fillers presents fewer barriers for both patients and surgeons such that a psychiatric diagnosis of gender dysphoria is not required to proceed with treatment, and consultation does not require multiple time-consuming and costly sessions. Injectables provide the opportunity to explore features one would desire should they pursue more permanent solutions. To promote health equity, this option may be more cost effective for patients whose finances limit surgical options and is less likely to be a procedure that is delayed, thus preventing psychological distress and patient distrust. Although not permanent, the literature endorses patient satisfaction with this route.2 For many, however, the ideal solution for facial feminization is a more permanent one, which can lead to increasingly positive health outcomes for transgender patients. Having some permanence in facial feminization is not only symbolic but offers patients an opportunity to align their gender identity and physical appearance after years of grappling with gender dysphoria. Surgical procedures of choice include hairline augmentation, rhinoplasty, blepharoplasty, cheek augmentation, upper lip lift, and tracheal shave among many others. Although undergoing these procedures is often the long-term goal, there may be more barriers to care, including psychiatric evaluations and preoperative workups for procedures requiring anesthesia.3 Additionally, these procedures are not without medical and surgical risks, and may transform the patient in ways they do not envision. Treating surgeons must listen to patients and set realistic expectations for each treatment approach, weighing all risks and benefits, including psychosocial, emotional, and financial considerations. It is important that the surgeon offers all available approaches and does not exclude procedures they may view as unnecessary. When healthcare professionals view these procedures as merely cosmetic, elective, or not worth the risk, they invalidate transgender health and become a threat to this group’s well-being. Making the decision to pursue facial feminization surgery should not be taken lightly, and it is critical for surgeons to be aware of identity formation and the emotional impact many patients experience in transforming their appearance and relinquishing a past view of the self. Advocacy, emotional intelligence, and gender humility will achieve better health outcomes, reduce stigma, and lead to trusting therapeutic relationships. Table 1 illustrates the potential issues patients may encounter and actionable responses the treating physician may use. Table 1. - Patient Issues and Physician Responses Potential Issues for Patient Actionable Response Financial instability Discuss patient financial planning and consider payment plans as available, including thought on long-term goals and physical transitional goals of patient. Injectable procedures will be first line because they remain one of the most affordable routes of aligning one with their gender identity. However, it is necessary to discuss the cumulative cost of consistent injectables if patient funds will continue to be scarce. Uncertainty about desired “look” Offer clear and informed consent about the duration of physical changes and the options for reversal/adjustment in the case of dissatisfaction with results. Propose injectable procedures that provide a nonpermanent result and encourage multiple consultation visits to collaborate on final desired “look.” Comorbidities posing significant health risks in setting of surgical procedures Psychological and spiritual well-being must be weighed against physical health risks in a nonjudgmental manner by physician. Keep in mind the importance of not underestimating the impact of emotional and psychological health in bolstering physical health for patients. Uncertainty about surgery as an option Explore patient hesitation in taking surgical step. Encourage injectable procedures that provide a nonpermanent result as appropriate. Unresolved emotional or psychological issues Initial consultation to determine patient goals and expectations in a nonjudgmental manner by the physician. Explore the extent to which a patient’s current physique poses a threat to long-term happiness and how successful any physical alterations will be in positively affecting patient health and wellness. Implore psychologically therapeutic approaches before or in conjunction with surgical ones. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.