The fight for transgender rights is in progress in many parts of the world. Beyond the ongoing policies on trans access to bathrooms and gender change on official documents, it is high time to raise awareness of transgender aesthetic treatments among clinical practitioners.
This comment piece, therefore, ventures deeply into the topic of transgender aesthetic surgeries. Starting with the evolution of transgender healthcare, I move on to explore types of surgeries for transgender individuals. This will be followed by a critique of support for trans aesthetic surgeries in the UK and beyond. Crucially, I look into what aesthetic treatments mean for the transgender community–while it is the job of aesthetic practitioners to focus primarily on patients' physical appearance, of important note is that the connection between body and mind is incredibly complex in the case of trans patients. This is because the dichotomy between body and soul is incredibly complex, problematic, and historically shaped by social ideologies.
As one could argue that transgender patient psychology is of equal significance in aesthetic nursing, I took the initiative to feature an interview in the second half of the article. On this occasion, I had the opportunity to speak with Ange La Furcia, Miss International Queen Colombia 2023, a trans woman herself and a PhD candidate at Cambridge University, researching lived experiences of beauty among trans women in Colombia. In conversation with Ange, I shall then direct the focus to the emotional side of transgender aesthetics.
Transgender individuals in clinical history
While transgender individuals have existed since ancient times, it was not until the past century when terms such as ‘transgender’ were coined and became more integrated into academic scholarship (see the work of trans scholars such as Susan Stryker). This in itself is also why the clinical history of transgenders has been challenging to study–in past centuries, when the term ‘transgender’ was not yet present, the concept of transgender may have been conceptualised in ways that the modern science historian may not fully understand.
Anecdotally, the first documented case of gender reassignment surgery was that of Dora ‘Dorchen’ Richter, a German person who underwent complete male-to-female gender change surgery. Under the care of Magnus Hirschfeld–a gender research pioneer at Berlin's Institute of Sexual Research in the 1920s and 30s–Dora underwent an orchiectomy (i.e., removal of testicles), a penectomy (i.e.m removal of the penis) and a vaginoplasty (i.e., creating a vagina in the body). Since then, transgender surgeries and treatments have expanded to include changes in the face (i.e., masculinisation and feminisation) (see the following section for an introduction to medical terms). It is important to note, however, that such historical references have been included in a larger panorama of what is now considered sex reassignment surgeries, (i.e., the Iranian cases - see below for more information). The history of these surgical procedures does not begin with a single case but rather a plurality of cases, and often differ according to different contexts of scholarly literature.
Surgeries and treatments for transgender people
The physical transformation of transgender individuals is a long and emotional process. Deciding which treatments and surgeries to undergo is the first step–it cannot be done without consideration of an individual's identity and the emotional trajectory involved. The paragraphs below introduce surgeries and treatments that mark the clinical transgender experience.
» … while it is the job of aesthetic practitioners to focus primarily on patients' physical appearance, of important note is that the connection between body and mind is incredibly complex in the case of trans patients. This is because the dichotomy between body and soul is incredibly complex, problematic, and historically shaped by social ideologies «
Hormonal therapy
A common treatment taken by male-to-female transgender individuals (i.e., transwomen) is that of hormonal therapy. Anti-androgens assist in blocking male hormones; intake of oestrogen and progestin also helps with developing features that are traditionally deemed as ‘feminine’, such as softer skin, breasts, and rounder hips.
Facial surgeries–facial feminisation and masculinisation surgeries
This is a series of procedures that reshape one's facial features to become more ‘feminine’. Procedures can be related to face contouring, nose reshaping, among others. This is often used by people for whom hormonal therapy does not fully help to shape the desired gender-affirming changes in the face.
Top surgeries–transfeminine and transmasculine top surgery
Mammaplasties (also spelled mammoplasties) are surgeries aimed at changing the size, shape, and texture of the breast. It is common for transwomen to receive augmentation mammaplasty, usually involving breast implants. Transmen may also choose to undergo reduction mammaplasty, which involves the removal of breast tissues. Some may even opt for a complete mastectomy, which comes with the added benefit of greatly reducing breast cancer risk.
Patients of such surgeries are not uniquely transgender, as there is a market for mammaplasties among cisgender women as well (Borumand et al, 2023).
Bottom surgeries–transfeminine and transmasculine bottom surgeries
Bottom surgeries involve the transformation of genitalia. For transwomen, this can be vaginoplasty, clitoroplasty and labiaplasty, which, as morphology of the term suggests, refer to the addition of a vagina, clitoris, and labia. Such surgeries are performed in addition to penectomies and orchiectomies, which respectively refer to the removal of the penis and testicles.
For transmen, bottom surgeries can include hysterectomy (i.e., the removal of a uterus); vaginectomy (i.e., the removal of a vagina) and also phalloplasty (i.e., penile implant).
Trans medical transitions
Noteworthy is that not all transgender people transition clinically (Vox, 2018). This could be due to financial-psychology barriers or simply no desire to do so. In detail, for instance, the US National Transgender Discrimination Survey in 2011 revealed that 14% of transwomen along with 72% of transmen do not wish to ever undergo full genital construction surgery. Among the transgender and gender-nonconforming respondents surveyed, 33% of them reported having transitioned surgically (i.e., having actually undergone surgery), while 61% reported having medically transitioned (having undergone hormonal therapy et cetera).
Access to transgender transformations in the UK and beyond
Gender-affirming healthcare is not equally accessible in different parts of the world–a phenomenon that can be explained by a plethora of factors such as societal-cultural values and differences in healthcare systems.
In the UK, an Internet search for ‘gender affirming surgery UK’ would bring you to the National Health Service's (NHS) ‘gender dysphoria’ page. Gender dysphoria, as a medical term, ‘describes a sense of unease that a person may have because of a mismatch between their biological sex and their gender identity’ (NHS, 2020). To many people, however, such a term may be deemed derogatory, as the term itself may carry a hint of gender dysphoria being a mental illness. Gender dysphoria is also not always experienced by all trans individuals, which puts into question the assessment of gender dysphoria as a primary step in sexual consultation clinics.
The NHS advises that trans individuals can seek support in ‘gender dysphoria clinics’. Gender dysphoria clinics amount up to only eight in the UK, and wait times are currently extremely long (some even counting up to two years). Individuals can undergo cosmetic treatments in private clinics, although costs vary according to the type of surgery or treatment. Looking at transgender clinics across the UK, a vulvoplasty (i.e., creation of a vulva) can cost around 19, 000 GBP or more. Breast augmentations can start from 8, 000 GBP and buttock lifts, 10, 000 GBP.
For many, gender reassignment surgery costs are astronomical, which is why there have been discussions worldwide on how such surgery can become more accessible. The work of Oxford scholar Johann Go (2018) summarises that, with healthcare rationing being inevitable, there are some voices stating the idea that gender reassignment surgery is largely a cosmetic procedure rather than a ‘medical’ one, and hence should not be publicly funded. There is also the saying that gender reassignment surgeries are not necessarily clinically effective, which may be why some people hesitate at the thought of funding it widely when other aspects of the health system are already not well-subsidised. I do acknowledge the concerns of both viewpoints; nonetheless, I also side with Johann Go that, with transgender people having among the highest suicide rates in some parts of the global society, there should be more flexibility in revising policies in this area.
Beyond the UK, in some modern geographical contexts, fear and reluctance to undergo gender reassignment surgery could be explained by violence towards the transgender community (Budhwani, 2017). However, contrary to popular belief, gender reassignment surgery may exist in countries known to be strongly religious in the modern context. In Iran, for example, where homosexuality is a capital offence, gender reassignment surgery becomes encouraged (The Economist, 2019). This idea, however, has been criticised, as it is seen as stereotypical and Islamophobic (see the work of Najmabadi).
» For many, gender reassignment surgery costs are astronomical, which is why there have been discussions worldwide on how such surgery can become more accessible «
Transgender aesthetics: in conversation with Ange La Furcia, Miss International Queen Colombia 2023
The differences in attitudes towards transgender people around the world propels me to think about the psychological trajectories of transgender individuals before and after their physical transformations. As with aesthetic surgeries for cisgender people, the journey does not stop at the surgery itself, but rather the lived experiences after the surgery in the longer term.
With this in mind, I made the initiative to interview an individual with ample personal experience and scholarly expertise in the role of beauty in transwomen. I have had the honour to speak with Ange La Furcia, Miss International Queen Colombia, with whom I was lucky enough to cross paths during my student years at Cambridge. Ange herself is currently a PhD candidate at the University of Cambridge, a trans scholar researching beauty and lived experiences among trans women in Colombia. Prior to coming to the UK, she was a sociologist at the University of Valle, Cali, Colombia (2009-2014), holding a Master's degree in Gender Studies, Politics, and Sexuality from the School for Advanced Studies in the Social Sciences EHESS, Paris, France (2017-2019). She is also a graduate of the École Normale Supérieure de Paris, Rue d'Ulm, majoring in Social Sciences and minoring in ‘Languages and Cultures of the Arab and Muslim World’ (2016-2020). In the years that I have known Ange, I have seen her as a source of inspiration for the trans community and beyond, an avid activist, and a wealth of much-needed insight. She is also working on a project called ‘Los Hijos del Paisaje: Memorias de Agua’ [Children of the Landscape: Water Memories], an initiative of symbolic reparation of the victims of armed conflict in the Colombian Insular Caribbean (the islands of San Andres), Providencia, and Santa Catalina.
» In the interviews they often ask when was the first time you identified as a trans person, or as a woman, or as a man, as if we needed to identify directly with an idea they have in mind. What a woman is and what a man is… it creates a lot of tension in the interview «
Ange's story
Born in Colombia, Ange's male-to-female transgender experience started early. Aside from her physical transformations, she took every opportunity she could to establish her gender identity as well. This included a gender change on her official documents in Colombia. A name change–one that aligned with her gender identity–was also made.
This transition was by no means easy; aside from having issues with immigration control at airports (where identity documents are being checked), there is also the lack of information on the possible services to access:
‘Some of us are scared to get access to treatments… you don't get advertisements or information in specific reviews or surgeries.’
From being a trans scholar to Miss International Queen Colombia 2023
For Ange, the thought of entering the Miss International Queen pageant–a pageant for transwomen–first occurred in 2017. It was interestingly in France, and not her native Colombia, where this idea was proposed to her. She was hesitant in the beginning, unsure of whether she fit the beauty standards or not. Certain barriers, coupled with Covid and the fact that she was still a Master's student in France, led her to postpone her entry for International Queen Colombia. Having now secured her success on a national level, Ange will represent Colombia in Miss International Queen this coming June in Thailand.
» … the [aesthetic] procedures are not the objective per se to confirm our lived experience, to feel better, or emotionally stable; it's not the final part of the process… it's as if we have in mind the idea of ending something and starting a new life, there is the before and the after. I think it is more complicated than that «
Ange's thoughts on the clinical experience of transgender individuals
Having physically transformed herself, Ange is vocal about how trans people are often examined under discriminatory lenses in a clinical setting. The coining of medical terms and concepts for transgender people, as Ange describes, is done under problematic frameworks that dismiss the importance of understanding the transgender experience as a complex lived experience. She states:
‘We have been described with many medical science terms and concepts. And they have been created by psychiatrists, and especially by endocrinologists.’
Gender dichotomy in clinics
Another problematic aspect of assessments prior to gender reassignment surgery is the tendency to dichotomise gender–this stands in contrast to the growing modern idea that gender should be fluid psychologically.
Especially in the cases of supporting trans people in cosmetic surgeries, there is the need to take this fluidity into account:
‘Another person is going to treat you, and all the time concerned about what is going to happen to your bodies. Because of the emphasis on the genitalia, … the difference in between two genders… as if there are two genders. In the interviews they often ask when was the first time you identified as a trans person, or as a woman, or as a man, as if we needed to identify directly with an idea they have in mind. What a woman is and what a man is… it creates a lot of tension in the interview.’
The transgender experience does not start nor end with aesthetic procedures
Crucially, Ange also believes that aesthetic gender reassignment procedures are not the beginning nor the end of the transgender experience. The procedure itself, while potentially powerful, is not the defining means of changing one's identity.
‘I want to say that when we're talking about surgery or medical treatments involving body transformation – in the case of trans people and non-binary people, gender-nonconforming people, or even cisgender people that don't feel that they fit in the gender norms of what is expected to be seen in a body–I do believe that a recommendation, not only for scholars by also for other people (those have been aware of different social movements, different feminist movements, or trans movements) is that the procedures are not the objective per se to confirm our lived experience, to feel better, or emotionally stable; it's not the final part of the process… it's as if we have in mind the idea of ending something and starting a new life, there is the before and the after. I think it is more complicated than that.’
As such, Ange thinks that transgender people's lived experience with beauty in the longer term is worth exploring. The trajectories of this lived experience post-surgery in the long run, hence, is deserving of attention not only in scholarship, but also in actual practice.
Conclusion: implications for aesthetic nurses
Even for aestehtic nurses who do not work uniquely with transgender people, it is pivotal for the nurse to understand that, just like cisgender patients, transgender individuals go through non-linear, long-term emotional trajectories in their pursuit of treatment. Their journey does not end upon completion of aesthetic procedures, and it is important to have a thorough conversation on how your services may support them in the longer term. Aesthetic medicine, after all, is meant to life-enhancing, and this physical-mental bridge is important to explore down the line. It is equally important to consider how aesthetics may differ for every individual in the modern, gender fluid world, where beauty may not necessarily conform to traditionally conceived norms. As a creator of beauty, the aesthetic practitioner shall bring beauty to life by critically contemplating how it enriches patients' lived experiences.