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During her first full day of recovery after undergoing gender transition surgery, Caitlyn Jenner had a panic attack, repeatedly asking herself, “What did I just do?”
The second-guessing, as recounted in July’s issue of Vanity Fair, didn’t last long and hasn’t returned for the 65-year-old, who grew up as Bruce, secretly donning his mother’s dresses and feeling like he wasn’t a boy.
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Still, it points to the emotional toll of such an invasive and life-changing procedure. World-renowned plastic surgeon Dr. Jeffrey Spiegel, who has performed facial feminization surgery on more than 1,000 people, says Jenner’s initial reaction was “incredibly atypical” because many patients feel empowered.
“It’s a sense of relief. It’s a rebirth,” says the chief of facial plastic and reconstructive surgery at Boston University Medical Center and professor at the Boston University School of Medicine.
After years of struggling with why they feel different from how they look, then coming to grips with understanding who they truly are and finally deciding to do something about it, the surgery can’t come soon enough.
“There’s this great sense of anticipation and importance,” says Spiegel, who is in Toronto this weekend to consult with patients. “The hardest part of surgery is after because you’ve done it and want to wake up and (see the result . . . But it takes a few weeks before you see it.”
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Facial feminization surgery is a series of procedures that involves adjusting the skull so the face looks more feminine. It can include forehead contouring, enlarging the eye sockets to make the eyes larger, lifting the eyebrows, augmenting the cheeks and adjusting the hairline and jawbone. And, it can also entail shaving the Adam’s apple.
“People like to use the adage that beauty is skin deep, but really it’s quite a bit deeper than that. Beauty goes down to the bone level.”
There are Canadian doctors who do facial feminization surgery, but it isn’t covered by OHIP. Sex reassignment surgery (changing a person’s sex), however, is covered if approved by the Adult Gender Identity Clinic at Toronto’s Centre for Addiction and Mental Health. (Jenner underwent facial feminization surgery, but not genital surgery.)
Because Spiegel is a pioneer and leader in the field, many Canadians travel to his clinic for facial feminization surgery. He has operated on more than 100 people in the last few years. Typically, surgery lasts four to 10 hours, and costs between a few thousand to tens of thousands of dollars, depending on how much work is done.
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Stacey Vetzal, a transgender woman from Oshawa and advocate for transgender rights, says the average annual income for a transgender person in Ontario is about $16,000, making facial feminization surgery “completely out of the realm of possibility for the vast majority.” Cost is one reason she’s never undergone the surgery.
“I had a period of time in my life when I very much stressed about my appearance,” says Vetzal, a volunteer with PFLAG Canada, a peer-support organization that deals with sexual orientation, gender identity and/or expression. “I’ve reached a point where I’m happy enough with my appearance.”
In Canada, there are no reliable statistics on how large the transgender population is because many choose not to be visible to the general public and medical system. But, “there’s a lot more than people think,” says Vetzal, noting the PFLAG chapter in Durham Region has experienced an “explosion of attendance of trans-identified individuals and their families over the past several years.”
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Over the past two decades, Spiegel has been studying what makes a face appear more feminine and how light patterns affect how the face is perceived, which has helped hone his technique.
“I can make a person look extremely feminine in a photograph, but if they sound like me, and sit the way I do, and walk like a man, they may not be seen the way they want to be seen,” says Spiegel.
So some transgender women will work with a speech therapist on overcoming typically male behaviours. Transgender males don’t need facial surgery because testosterone masculinizes a woman’s face.
Spiegel has performed facial feminization surgery on patients from 17 to 80 years old and says much of Jenner’s story is typical of what transgender women experience.
Certainly, Jenner’s celebrity is atypical: the former decathlete set a world record at the 1976 Olympics and went on to be part of the reality TV show Keeping Up with the Kardashians.
But, like Jenner, many patients knew at a young age that although they looked like a boy, they didn’t feel like one. They hid their true feelings, pursuing sports and stereotypically macho professions, becoming, for instance, a police officer, firefighter, soldier or bodybuilder, Spiegel says. In essence, they tried to be overly-masculine to convince themselves they were men, even though they knew themselves to be women. But as time went on, it became impossible to deny their true self, he explains.
The best time to have facial feminization surgery is when it can coincides with a big life change, such as starting university or retiring, Spiegel says, adding those in male-dominated professions often visit him a few weeks before retirement.
He says it’s rare for patients to experience repercussions from undergoing surgery, such as losing their job or support from family and friends. But he notes about 50 per cent of marriages end up in divorce.
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“In almost every case, I found that the family comes around and understands, given the chance to process it,” he says. “Most people who have the surgery find that everything gets better . . . People who didn’t accept them before now accept them.”