Caitlyn Jenner's debut on the cover of Vanity Fair this week has garnered much media attention and shed light on what it means to be transgender. It has also raised awareness of the surgeries many transgender women choose to undergo.
Formerly Bruce Jenner, Caitlyn had a 10-hour facial feminization surgery in March of this year. In an interview with Vanity Fair, Jenner said the operation took twice as long as expected. After an initial panic attack following the surgery, she spoke with a counselor and put the second-guessing behind her. Jenner told the magazine she firmly stands by her decision:
"If I was lying on my deathbed and I had kept this secret and never ever did anything about it, I would be lying there saying, 'You just blew your entire life. You never dealt with yourself,' and I don't want that to happen," she said.
Though Jenner had taken steps toward feminization in the past, including taking hormones that resulted in breast growth and procedures for facial hair removal, her facial surgery was the final step of her transition. Vanity Fair reported that she did not have genital surgery.
Facial feminization surgery can include a number of procedures, including the repositioning and reshaping of the eyebrows and hairline, chin and jaw reductions, cheek augmentation, lift lips, and tracheal shaving, or reducing the size of the Adam's apple, Dr. Jeffrey Spiegel, a Boston-based plastic surgeon who specializes in facial feminization surgery, told CBS News. Spiegel was not involved in Jenner's care.
While Spiegel also performs such procedures on women born as females and even men who wish to remain male but soften their features, many of the patients he operates on are transgender women.
"For transgender women specifically, the problem that they have is that they know they're a woman but everyone who sees them sees a man," he said. "Transgender women who come to see me have already sorted through therapy, counseling, and time, that they are women and want to look more feminine."
During a consultation, Spiegel has lengthy conversations with his patients about what they're looking for and what they can expect from the surgery. Though a psychological consultation is not required, as it is for genital surgery, Spiegel said he has turned people away if he thinks they are not ready.
If they both agree to go ahead with the surgery, Spiegel discusses in great detail the procedures available. "They tell me what parts of their face that they've been bothered by and I will go through and do an analysis and discuss what parts of the face I think are sending masculine messages," he said. "Based on that, we'll figure out a treatment plan."
However, not every transgender woman undergoes facial feminization surgery, either by choice or because of lack of access, and such procedures are not necessary to identify as transgender.
Largely considered a cosmetic procedure by insurers, facial feminization is not covered by most health insurance policies. Depending on what work is being done, the surgery can cost upwards of several thousand dollars, Spiegel said.
Many transgender women cannot afford such costly procedures. "The reality is many trans people may not ever be able to have surgery that many consider a big piece of the transition," said Sasha Alexander, director of membership at Sylvia Rivera Law Project, a legal project in New York City working to advance the rights of transgender people, including trans-inclusive health care and access to these procedures.
Alexander, who identifies as a trans person of color, explained that within the transgender community there are many different viewpoints surrounding gender-affirming procedures -- from genital surgeries to hormone therapy to facial alterations. "Some feel they were born with a birth defect and surgeries correct that. Others may feel pushed in to getting surgery, that it's something we're supposed to do. Others choose not to have surgery to push back against gender norms. Some people may have surgery and then don't identify as trans anymore. There are many different experiences within the community."
Facial feminization surgery can also be an answer to safety issues for many transgender women, Alexander said. "They experience so much violence and harassment and discrimination, and so it's not just a cosmetic issue, it is a life-saving surgery."
While Jenner has been widely celebrated for stepping out as her true self, Alexander pointed out that her story prompted mixed emotions among some transgender people who don't have Jenner's resources. "For many of those in our community, that is not realistic, and it can be painful to watch someone have that transformation in days when it's not accessible to people who may be most vulnerable and really need that."
But Alexander also acknowledged that there are certainly positives to the wide reach of Jenner's story. "If anything, it helps us bring up conversations about trans health and the life-saving procedures that are really important in the community. Her story opens the door for people to start talking about it in places where people may have never wanted to have these kinds of conversations."