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Gender-affirming facial surgery: Anatomy and fundamentals of care

  • Tania Benjamin
    Affiliations
    Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, 2233 Post Street, 3rd Floor, San Francisco, CA 94115
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  • P. Daniel Knott
    Affiliations
    Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, 2233 Post Street, 3rd Floor, San Francisco, CA 94115
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  • Rahul Seth
    Correspondence
    Corresponding Author: Rahul Seth, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco
    Affiliations
    Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, 2233 Post Street, 3rd Floor, San Francisco, CA 94115
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Open AccessPublished:January 18, 2023DOI:https://doi.org/10.1016/j.otot.2023.01.002

      Abstract

      Caring for patients who identify as transgender and gender diverse (TGD) requires a ground level understanding of proper patient communication, a framework for decision-making surrounding medical and surgical interventions, and an awareness of obstacles surrounding healthcare. The objective of this chapter is to highlight appropriate terminology and definitions, discuss the current standards of care for transgender health, raise awareness of the barriers to healthcare access facing the TGD population, and discuss basic facial anatomy and sexual dimorphisms. Gender incongruence occurs when birth-assigned sex and gender identity differs for an individual, and gender dysphoria is the distress felt in this state. Persons who experience gender dysphoria may seek gender-affirming hormone therapy or surgery. Access to care is not straightforward, and the current standards of care aim to provide a guideline for administration of hormones and surgery. In order to offer the highest level of care, surgeons should have a fundamental understanding of issues surrounding the TGD community combined with a robust comprehension of facial features characterizing gender.

      Key words

      Gender Identity and Awareness

      An estimated 1 to 1.4 million trans and gender diverse (TGD) individuals currently live in the United States.
      • Meerwijk EL
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      Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples.
      ,
      • Flores AR
      • Herman Jody L.
      • Gates Gary J
      • Brown Taylor N.T
      How many adults identify as transgender in the United States.
      To understand gender identity, it is important to appreciate the difference between sex and gender. Sex is the combination of genetic, biologic, and physical traits that define a person as male or female, and is typically assigned at birth.
      • Factor RJ
      • Rothblum ED.
      A study of transgender adults and their non-transgender siblings on demographic characteristics, social support, and experiences of violence.
      Gender, on the other hand, is viewed as a social construct in the medical community. It is one's definition of identity in the context of how one feels and interprets one's body and emotions in one's environment, irrespective of biology.
      • Factor RJ
      • Rothblum ED.
      A study of transgender adults and their non-transgender siblings on demographic characteristics, social support, and experiences of violence.
      With sex and gender identity being similar, the individual is considered cisgender. Gender incongruence occurs when biologic sex assigned at birth and gender identity disagree. Gender identity for some individuals is fixed, and others may have fluid gender state or may experience gender as non-binary. Therefore, the term trans and gender diverse (TGD) is recommended and utilized throughout this issue. TGD individuals may seek different domains of gender affirmation, including social, legal, medical, and surgical affirmation.
      Gender awareness as either male or female forms evolves during infancy and childhood and can be influenced by environmental and parental interactions. Studies have examined and described this process, but further research is needed to fully understand the process of gender identification. Factors influencing gender identity include a complex interplay between cultural, environmental, and biological factors.
      • Steensma TD
      • Kreukels BPC
      • de Vries ALC
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      Gender identity development in adolescence.
      • Rosenthal SM.
      Approach to the patient: transgender youth: endocrine considerations.
      • Saraswat A
      • Weinand JD
      • Safer JD.
      Evidence supporting the biologic nature of gender identity.
      It is important to note that gender identity varies from gender expression, which is how one conveys themselves to others in a gendered manner. Gender expression may not always align with gender identity.
      At birth, there is likely a biological correlation to gender identity. Several studies have examined the role that genetics and hormones play in influencing gender identity. For example, identical twins have greater rates of transgender identity between siblings than fraternal twins.
      • Heylens G
      • De Cuypere G
      • Zucker KJ
      • et al.
      Gender identity disorder in twins: a review of the case report literature.
      Prenatal androgen exposure has also been examined in gender development. Individuals with congenital adrenal hyperplasia who are exposed to additional androgens in utero have increased rates of male gender identity.
      • Dessens AB
      • Slijper FME
      • Drop SLS.
      Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia.
      Patients with complete androgen insensitivity have female gender identity.
      • Mazur T.
      Gender dysphoria and gender change in androgen insensitivity or micropenis.
      Further research is needed to understand the role of perinatal hormone levels in sexual orientation and gender identity. Studies have not shown differences in sex hormone levels between cis- and transgender individuals, supporting a complexity of influences.

      Appropriate Terminologies and Definitions

      It is important to distinguish between the terms used to describe the TGD community versus the terms the TGD community uses to describe themselves and their experiences. Trans is often used to describe individuals who identify with a gender that does not align with the birth-assigned sex. For example, a ‘transgender’ or ‘trans’ man was assigned the female sex at birth but identifies as a man. Likewise, a ‘transgender’ or ‘trans’ woman was assigned the male sex at birth but identifies as a woman. “Genderqueer” and “non-binary” describe individuals with genders that do not exist within the duality of “woman” or “man.” “Non-binary” also includes many identities, such as ‘agender’ or having no gender, ‘bigender’ or having two genders, and ‘genderfluid’ or those with genders evolving multiple identities over time.
      • Association American Psychological
      Guidelines for psychological practice with transgender and gender nonconforming people.
      • Porter KE
      • Brennan-Ing M
      • Chang SC
      • Dickey LM
      • Singh AA
      • Bower KL
      • et al.
      Providing Competent and Affirming Services for Transgender and Gender Nonconforming Older Adults.
      Trans Bodies, Trans Selves: A Resource by and for Transgender Communities.
      The language used to describe the diversity of gender identities has undergone constant shifts. Some terms that may have been accepted in the past (i.e. ‘transvestite’ and ‘transsexual’) are no longer within the preferred TGD-affirming language. With the diversity of gender identities, TGD persons use words with which they are the most comfortable. Likewise, providers should ask the patient to provide name, pronoun, and gender identity. Every effort should be made by the medical community to adhere to these. Best practice includes ensuring the correct information provided by the patient is within the medical record and is acknowledged and utilized by all personnel.
      Terminology such as “stealth” or “passing” are contentious among the TGD community, so are best used by the TGD community alone and not by cisgender providers. Terms that described how well gender expressions fit within cisgender standards of manhood or womanhood likely fell out of favor due to their dependance on cisgender norms. Patients, however, may describe a desire to “go stealth” or “pass,” indicating that the public would not be able to identify them as TGD. A complete list of pertinent terminology is listed in Table 1.
      Table 1Terminologies and definitions
      Biological sex, biological male or femaleThese terms refer to biologic construct of genetic and physical traits that determine whether someone is male or female and typically assigned at birth. These terms can be imprecise and promote binary and permanent states, therefore they are avoided.
      CisgenderAn umbrella term for those people whose gender identity and/or gender expression is similar to the sex assigned at birth.
      Gender-affirming treatmentRefers to a treatment, procedure, or medication for those who want to adapt their bodies to the experienced gender, typically by means of hormones and/or surgery. This term is broadly applicable to various treatments, for example “gender-affirming hormone therapy,” “gender-affirming facial surgery.” Terms that are similar but are now less commonly used are “gender reassignment” and “gender-confirming”.
      Gender affirmation, gender transitionAn overall process of alignment of physical characteristics and/or gender expression with gender identity. “Gender confirmation” is a similar but less commonly used term.
      Gender dysphoriaThis is the discomfort, distress, and/or unease experienced if gender identity and sex recorded at birth are not completely congruent. In 2013, the American Psychiatric Association released the fifth edition of the DSM-5, which replaced “gender identity disorder” with “gender dysphoria” and changed the criteria for diagnosis. Not all transgender persons have dysphoria.
      Gender expressionThis refers to an individual's external manifestations and communications of gender, expressed through one's name, pronouns, clothing, haircut, behavior, voice, speech, or body characteristics.
      Gender identity, experienced genderOne's internal, deeply held sense of gender. Most people have a gender identity of man or woman (or boy or girl). For some people, their gender identity does not fit neatly into one of those two choices. Unlike gender expression, gender identity is not visible to others.
      Gender identity disorderThis is the term used for gender dysphoria / gender incongruence in previous versions of the DSM (see “gender dysphoria”). The ICD-10 still uses the term for diagnosing child diagnoses, but ICD-11 has proposed using “gender incongruence of childhood.”
      Gender incongruenceThis is an umbrella term used when the gender identity and/or gender expression differs from what is typically associated with the designated gender. Gender incongruence is also the name of the gender identity–related diagnoses in ICD-11. Not all individuals with gender incongruence have gender dysphoria or seek treatment. The term “gender variance” can be similarly used but is less common.
      Gender roleThis refers to behaviors, attitudes, and personality traits that a society (in a given culture and historical period) designates as masculine or feminine and/or that society associates with or considers typical of the social role of men or women.
      Sex designated at birthThis refers to sex assigned at birth, usually based on visualized genital anatomy.
      SexThis is a broad term that refers to attributes that characterize biological maleness or femaleness. The best-known attributes include the sex-determining genes, the sex chromosomes, the H-Y antigen, the gonads, sex hormones, internal and external genitalia, and secondary sex characteristics.
      Sexual orientationAn individual's enduring physical and emotional attraction to another person. Gender identity and sexual orientation are not the same. Irrespective of their gender identity, transgender people may be attracted to women (gynephilic), attracted to men (androphilic), bisexual, asexual, or queer.
      TransgenderAn umbrella term for those people whose gender identity and/or gender expression differs from what is typically associated with their sex designated at birth.
      Transgender male, trans manRefers to individuals assigned female at birth but who identify and live as men.
      Transgender woman, trans womanRefers to individuals assigned male at birth but who identify and live as women.
      TransitionThe process during which transgender persons change their physical, social, and/or legal characteristics consistent with the affirmed gender identity. Prepubertal children may choose to transition socially only.
      TranssexualThis is an older term not currently used that originated in the medical and psychological communities to refer to individuals who have permanently transitioned through medical interventions or desired to do so.
      Adopted from:
      1. Hembree, W. C. et al. (2017). "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline." J Clin Endocrinol Metab 102(11): 3869-3903.
      2. Safer, J. D. and V. Tangpricha (2019). "Care of the Transgender Patient." Ann Intern Med 171(1): ITC1-ITC16.

      Gender Dysphoria and Gender Incongruence

      Gender dysphoria is a diagnosis that encompasses the psychological distress a person feels when there is incongruence between gender identity and birth assigned sex. In the DSM-5, this feeling must persist at least 6 months and manifest with at least 2 diagnostic criteria (Table 2).
      Table 2DSM-5 criteria for gender dysphoria in adults and adolescents
      • A
        The DSM-5 defines gender dysphoria in adolescents and adults as a marked incongruence between one's experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:
      • 1
        A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
      • 1
        A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
      • 1
        A strong desire for the primary and/or secondary sex characteristics of the other gender
      • 1
        A strong desire to be of the other gender (or some alternative gender different from one's assigned gender)
      • 1
        A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender)
      • 1
        A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender)
      • A
        In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      Both Criteria A and B must be fulfilled to reach diagnosis of gender dysphoria.
      From: Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition. American Psychiatric Association. 2013
      In the 2012 WPATH (World Professional Association for Transgender Health) “Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7,” the clinical criteria (Table 3) for diagnosis of gender incongruence or TGD identity in a pediatric, adolescent, or adult patient requires the clinician to (a) determine the presence of a persistent gender identity that does not align with birth-assigned sex, (b) ensure patient's competency and capacity to make informed medical decisions regarding the medical or surgical interventions for gender affirmation, and (c) ensure mental health conditions that could confound diagnosis are reasonably controlled. A psychiatrist is often necessary to co-manage mental health conditions, as TGD individuals have higher prevalence of depression, anxiety, and suicidality, potentially due to experiences of transphobia.
      • Brown GR
      • Jones KT.
      Mental Health and Medical Health Disparities in 5135 Transgender Veterans Receiving Healthcare in the Veterans Health Administration: A Case-Control Study.
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      Profound health-care discrimination experienced by transgender people: rapid systematic review.
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      Prevalence of anxiety symptoms and disorders in the transgender population: A systematic review of the literature.
      Other conditions that may coincide with gender incongruence or gender dysphoria include obsessive compulsive disorder, psychoses, body identity integrity disorder, and body dysmorphic disorder.
      • Safer JD
      • Tangpricha V.
      Care of the Transgender Patient.
      ,
      • Hembree WC
      • Cohen-Kettenis PT
      • Gooren L
      • et al.
      Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.
      • First MB.
      Desire for amputation of a limb: paraphilia, psychosis, or a new type of identity disorder.
      • Johnson TW
      • Wassersug RJ.
      Gender identity disorder outside the binary: when gender identity disorder-not otherwise specified is not good enough.
      Patients should undergo psychological evaluation prior to any medical or surgical intervention to ensure mental health conditions are not confounding a diagnosis of gender incongruence.
      Table 3ICD-11 criteria for gender incongruence
      A marked and persistent incongruence between the gender felt or experienced and the gender assigned to birth. This incongruity is manifested in at least two of the following criteria:
      • -
        Strong dislike or disagreement with primary or secondary sexual characteristics due to incongruence with the experienced gender.
      • -
        Strong desire to get rid of some of those sexual characteristics due to the incongruence with the experienced gender.
      • -
        Strong desire to have the primary or secondary sexual characteristics of the experienced gender.
      • -
        Strong desire to be treated and accepted as a person of the felt gender.

      Role of Hormone Therapy

      Medical affirmation of gender identity involves pubertal suppression or gender-affirming hormones. Hormone therapy allows patients to attain secondary sex features aligning with the patient's gender incongruence while helping to suppress endogenous sex hormones producing undesired sex features incongruent with their gender incongruence. Prior to initiation of medical treatment, patients must undergo (a) psychological evaluation, (b) assessment of decision-making capacity, (c) discussion regarding risks and benefits of hormone therapy, and (d) pre-initiation labs.
      Psychosocial assessment prior to intervention is important to ensure confounding mental health conditions are controlled. Also, patients benefit from having a “lived experience” of at least one year in their congruent gender. This differs for each patient and may include social transition of name, pronoun, dress, and other personal aspects. For patients with an uncomplicated presentation, a primary care provider with adequate proficiency with hormone therapy may manage the transition. However, in patients with complicated presentations, a multidisciplinary team that involves a mental health provider is the optimal approach. Providers with sufficient experience must assess for the gender incongruence criteria mentioned above, but if the diagnosis is unclear, a qualified mental health provider should be involved. Providers who initiate hormone therapy are not limited to endocrinologists and can include primary care physicians, gynecologists, physician assistants, and advanced practice nurses.
      Next, decision-making capacity through informed consent must be assessed. TGD patients should demonstrate understanding both of their gender identity and the various aspects of their desired treatment, indicate treatment preference, understand how treatment will impact their lives, and show their capacity to reason through different options and the consequences deriving therefrom. Once confirmed that the patient has the capacity to understand the risks and benefits of the interventions, the physician and patient should work together to initiate medical therapy.
      Preparing for medical therapy involves a discussion of timing, risks, and benefits with the patient. A shared decision-making approach should exist between the patient and physician. Patients must also undergo laboratory testing, such as potassium levels if spironolactone will be used or CBC if testosterone will be initiated.
      Medical hormone therapy involves either masculinizing or feminizing hormones. It should take into consideration patients’ underlying comorbid medical conditions, psychosocial factors, and overall goals. Masculinizing hormone therapy involves the initiation of exogenous testosterone, which is typically sufficient to suppress endogenous gonadotropins and raise physiologic male testosterone levels. This outcome includes reduction of adipose tissue from the cheek, facial skeletal bone growth, and development of facial hair.
      • Hembree WC
      • Cohen-Kettenis PT
      • Gooren L
      • et al.
      Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.
      ,
      • Tebbens M
      • Nota NM
      • Liberton NPTJ
      • et al.
      Gender-Affirming Hormone Treatment Induces Facial Feminization in Transwomen and Masculinization in Transmen: Quantification by 3D Scanning and Patient-Reported Outcome Measures.
      Feminizing hormones involve dual therapy to both (a) supply exogenous estrogen and (b) suppress androgen secretion or action. Feminizing hormone therapy leads to softening of skin, fat redistribution, and increase of cheek tissue.
      • Hembree WC
      • Cohen-Kettenis PT
      • Gooren L
      • et al.
      Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.
      ,
      • Gorin-Lazard A
      • Baumstarck K
      • Boyer L
      • et al.
      Is hormonal therapy associated with better quality of life in transsexuals? A cross-sectional study.
      However, it will not reduce facial hair, which will typically require laser or electrolysis to reduce/remove, and it does not reduce the size of the facial skeleton.
      • Marks DH
      • Hagigeorges D
      • Manatis-Lornell AJ
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      • Senna MM.
      Excess hair, hair removal methods, and barriers to care in gender minority patients: A survey study.
      Given the changes to the facial skeleton that testosterone can produce while estrogen therapy does not, surgical masculinization of the face is less commonly performed than feminization surgery. However, indications and awareness of both feminization and masculinization surgery continue to mature.
      While generally safe, risks of hormone therapy include irreversible physical change and impact on future reproductive capability. Furthermore, the choice of medical therapy will depend on pubertal stage. While post-pubertal therapy is outlined above, in the pre-pubertal or pubertal stage, puberty blockers may be used as early as Tanner stage 2. If the desire to continue gender-affirming hormone therapy persists at age 16, patients can be transitioned to hormone therapy. At age 18, patients can decide whether to undergo gender-affirming surgery.
      • Hembree WC
      • Cohen-Kettenis PT
      • Gooren L
      • et al.
      Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.

      WPATH Standards of Care

      The World Professional Association of Transgender Health (WPATH) was formed to offer clinicians and surgeons a framework to assist patients seeking to undergo medical and surgical transitions. The organization was previously known as the Harry Benjamin International Gender Dysphoria Association and was developed by a group of psychologists and clinicians in 1979. They created the initial guidelines for providing gender-affirming care, known as “Standards of Care – The hormonal and surgical sex reassignment of gender dysphoric persons.” While these guidelines have been used by insurance companies and numerous medical societies, they are mainly based on clinical consensus and expert knowledge rather than informed by high quality research.

      Process of Obtaining Surgery

      The WPATH ‘Standard of Care’ guidelines include masculinizing and feminizing facial surgery under the category of gender-affirming surgeries. Unlike genital surgery, WPATH does not provide specific criteria that should be met prior to other procedures, such as facial surgery. The criteria for undergoing genital surgery includes being at age of majority in the respective country, having a lived experience in the congruent gender role for at least one year, undergoing hormone therapy for at least one year, and ensuring stabilization of other mental health conditions with 2 referrals from mental health providers. Due to the lack of specific criteria or guidelines for facial surgery, along with the cosmetic connotation of facial surgery, insurance companies had restricted coverage for individuals undergoing these surgeries. Currently, insurances vary in their coverage for these procedures and some surgeons performing facial gender-affirming surgeries (FGS) may not accept insurance.
      Referral for surgery can be made by a qualified mental health professional. The referral typically will include the patient's history, including medical, social, and surgical history. For chest surgery, 1 referral is typically required from a qualified mental health professional whereas 2 are required for genital surgery. The content of referrals should include: gender identity and traits, the psychosocial evaluation along with any other mental health conditions, duration of the relationship between mental health provider and patient, indication that the patient has met criteria and rationale for supporting the patient's request, indication that informed consent has been obtained, and a statement that the mental health provider is open to care coordination. While mental health screening is required prior to medical or surgical intervention for gender dysphoria, psychotherapy is not a mandatory requirement.

      World Professional Association for Transgender Health (WPATH). https://www.wpath.org/provider/search

      Medical Necessity

      Gender-affirming medical and surgical management allows patients with gender dysphoria to improve recognition as the gender with which they identify. Research has shown that gender-affirming surgeries improve mental health and quality of life, social relationships, body discontent, and employment status.
      • Kuiper B
      • Cohen-Kettenis P.
      Sex reassignment surgery: a study of 141 Dutch transsexuals.
      Specifically, studies on facial feminization surgery demonstrate improved body dissatisfaction and congruence with identified gender.
      • Isung J
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      • Farnebo F
      • Lundgren K.
      Craniofacial Reconstructive Surgery Improves Appearance Congruence in Male-to-Female Transsexual Patients.
      Voice surgery and speech therapy have also allowed for increased perception of femininity by raising pitch.
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      Female-to-male transgender quality of life.
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      Mental Health of Transgender Children Who Are Supported in Their Identities [published correction appears in Pediatrics. 2018 Aug;142(2):].
      Despite this, insurance coverage may not include voice or facial gender-affirming surgeries due to the notion that these procedures are ‘cosmetic.’ However, the face is the most visible aspect of the human body and specific facial features can identify one as a man or woman. Similarly, speech also helps discern whether one is a man or woman based on pitch, articulation, and tone. Dissonance between physical appearance and gender identity predisposes TGD individuals to judgement due to social stigma.
      • Hembree WC
      • Cohen-Kettenis PT
      • Gooren L
      • et al.
      Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.
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      Therefore, facial and voice surgery should be deemed medically necessary for the treatment of gender dysphoria. Numerous professional medical associations and the WPATH have called for insurances to cover all aspects of transgender care.

      Barriers to Accessing Care

      Despite the work being done to improve access to transgender care, several notable barriers still exist and are deeply rooted in systemic biases. Socioeconomic status, race, education level, geographic location, and insurance status are a few of the challenges that prevent TGD persons from accessing the care they need.
      • Safer JD
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      Care of the Transgender Patient.
      The social stigma surrounding the TGD community has caused higher rates of discrimination, violence, suicide, and high-risk behaviors in the community.
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      Socioeconomic Status

      Socioeconomic status impacts access to care. This is a particular problem for the TGD community, as there are limited capable providers and resources in a given region, especially in rural regions.
      • Whitehead J
      • Shaver J
      • Stephenson R.
      Outness, Stigma, and Primary Health Care Utilization among Rural LGBT Populations.
      Studies have shown that TGD persons earning less than $50,000 are at higher risk of healthcare access denial than those who make more than $100,000. Similarly, higher education also improves access to medical care and an improved chance at avoiding healthcare restrictions.
      • Kattari SK
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      • Kinney MK.
      Intersecting Experiences of Healthcare Denials Among Transgender and Nonbinary Patients.

      Discrimination and Racism

      Social discrimination contributes to increased impediments in accessing healthcare. Studies have shown higher rates of unemployment in the TGD community, potentially due to workplace discrimination because of social stigma, which contributes to housing insecurity.
      • Rowe D
      • Ng YC
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      Addressing transgender patients’ barriers to access care.
      Lack of support from peers and family during transition also contributes to poorer mental health among the TGD community, leading to depression, anxiety, and suicidal ideations.
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      Health Care Utilization, Barriers to Care, and Hormone Usage Among Male-to-Female Transgender Persons in New York City.
      Research indicates those with stronger social support are 82% less likely to engage in self harm.
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      Addressing transgender patients’ barriers to access care.
      In addition to discrimination against TGD persons, racism against those who are both TGD and an ethnic minority represents the overlapping and amplification of biases and the raising of barriers. Studies have established that minorities experience inferior healthcare due to healthcare disparities and systemic biases associated with race. Clinician biases and racism, whether conscious or unconscious, can ultimately result in patient mistrust of the medical system, especially in the case of TGD patients.
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      • et al.
      The perspectives of health professionals and patients on racism in healthcare: A qualitative systematic review.
      Surveys of the TGD community reveal that TGD individuals feel they would get superior medical care if they were a cisgender person of color or a white/Caucasian TGD person.
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      Educating providers and increasing awareness about the TGD community at various levels of training will help dispel this experience of discrimination.

      Immigration Status

      Immigration may worsen access to healthcare for various reasons. Patients who come from countries where transition is illegal may be less likely to seek care in the US.
      • Kimberly LL
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      • Friesen P
      • et al.
      Ethical Issues in Gender-Affirming Care for Youth.
      Additionally, literacy, cultural differences, and language barriers may compound apprehension. Little research has been performed to determine the experiences of TGD immigrants.

      Anatomy

      The face is central to gender presentation as it, along with the neck, is the most visible part of the human body. Certain facial characteristics are associated with more masculine versus feminine perception. For example, males tend to have wider jaws and thick facial hair whereas females have narrower jaws and softer skin. The distribution of fat in the face also can impact the the recognition of femininity. In order to alter facial appearance to boost masculinity or femininity, it is important to first understand the basic differences in facial features between males and females. A thorough understanding of these variations can help guide patient discussions and surgical planning.
      The face is comprised of bone, muscle, fat, and skin, and the combination of these is based on a multitude of factors. An individual's genetics, racial and ethnic background, age, and sex impact facial appearance. Facial appearance can widely range from individual to individual, but certain key features and familiar sexual dimorphisms help define male or female. In the neonatal and early childhood stages, these differences are very subtle.
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      • Claes P.
      Spatially dense morphometrics of craniofacial sexual dimorphism in 1-year-olds.
      Advancements in collecting morphometric facial data has led to a more precise understanding of the variations that exist between the male and female face. For example, the male face tends to be longer and wider with a flatter forehead. On the other hand, females have a more rounded structure with a higher upper face.
      • Ferrario VF
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      ,
      • Mydlová M
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      Sexual dimorphism of facial appearance in ageing human adults: A cross-sectional study.
      Studies have evaluated the degree of sexual dimorphism and attractiveness and demonstrated a potential correlation, which could indicate a potential mate's underlying health.
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      A new data-driven mathematical model dissociates attractiveness from sexual dimorphism of human faces.
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      Symmetry, sexual dimorphism in facial proportions and male facial attractiveness.
      (p),
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      Female appearance: Facial and bodily attractiveness as shape.
      ,
      • Mueller U
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      Facial dominance in Homo sapiens as honest signaling of male quality.

      Facial Analysis

      A framework for approaching facial analysis is important, and many forms of examining the face exist. Typically, the face is divided into proportions, with each space being assessed individually. Renaissance artists suggested dividing the face into symmetric vertical fifths and horizontal thirds.
      • Lakhiani C
      • Somenek MT.
      Gender-related Facial Analysis.
      However, racial and ethnic limits of this model exist. Other methods of facial comparison include the Powell and Humphrey's aesthetic angles and the Frankfurt horizontal planes.
      • Prendergast PM.
      Facial Proportions.
      In gender-affirming facial surgery, the horizontal-thirds framework is prevalent in describing facial structure for surgical planning. Thus, in the following sections, the facial anatomy is divided into three main areas: (1) upper third (forehead and the eyebrow), (2) middle third (orbit, nose, and cheeks), and (3) lower third (lips, mandible, and chin).

      Upper Face

      The upper face starts superiorly at the trichion and extends inferiorly to the glabella (Figure 1). When evaluating this region, the hairline, forehead, glabella, and brows should be assessed. The upper face plays a critical role in expressing gender. A study by Brown and Perrett showed that when certain facial features are displayed in isolation, a significant amount of information identifying gender is revealed by the eyes and eyebrows.
      • Brown E
      • Perrett DI.
      What gives a face its gender?.
      In addition, a study modifying the forehead of male photographs was more feminizing than modifications, in both frontal and profile view, to the mid- and lower-face.
      • Spiegel JH.
      Facial determinants of female gender and feminizing forehead cranioplasty.
      Beyond the forehead, the hairline shape and location also allude to a certain gender. The female hairline tends to be closer to the mid-glabella (∼5.0-5.8 cm average) and has a rounded or rectangular, non-receding shape.
      • Dang BN
      • Hu AC
      • Bertrand AA
      • et al.
      Evaluation and treatment of facial feminization surgery: part I. forehead, orbits, eyebrows, eyes, and nose.
      ,
      • Sirinturk S
      • Bagheri H
      • Govsa F
      • Pinar Y
      • Ozer MA.
      Study of frontal hairline patterns for natural design and restoration.
      In contrast, male hairlines tend to have an M-shape with greater soft tissue hollowing and recession along the temporal hairline. The average distance from the trichion to mid-glabella is 6.0-8.0 cm in males.
      • Dang BN
      • Hu AC
      • Bertrand AA
      • et al.
      Evaluation and treatment of facial feminization surgery: part I. forehead, orbits, eyebrows, eyes, and nose.
      Figure 1
      Figure 1Typical differences between the upper-third of the male and female face in A) frontal and B) lateral view, including the hairline, forehead, and brow.
      The bony framework of the upper face also varies between males and females. The frontal bone of females tends to slant vertically with a more rounded and smoother convexity. In males, the frontal bone is more horizontal at the supraorbital ridge and forehead.
      • Tanikawa C
      • Zere E
      • Takada K.
      Sexual dimorphism in the facial morphology of adult humans: A three-dimensional analysis.
      ,
      • Del Bove A
      • Profico A
      • Riga A
      • Bucchi A
      • Lorenzo C.
      A geometric morphometric approach to the study of sexual dimorphism in the modern human frontal bone.
      The supraorbital ridge curvature in males tends to appear discontinuous with the forehead, leading to a projected glabella and a narrower nasofrontal angle. Females have a minimal supraorbital ridge, and as a result have a flatter glabella with a more obtuse nasofrontal angle.
      • Lakhiani C
      • Somenek MT.
      Gender-related Facial Analysis.
      ,
      • Garvin HM
      • Ruff CB.
      Sexual dimorphism in skeletal browridge and chin morphologies determined using a new quantitative method.
      Lastly, eyebrow shape, though cosmetically modifiable, plays an important role in gender identification. The thinner and arched appearance lends a more feminine appearance, whereas flatter and heavier appearances tends to be more masculine.
      • Spiegel JH.
      Facial determinants of female gender and feminizing forehead cranioplasty.
      The eyebrow sits more inferiorly on males, typically at the supraorbital rim compared to several millimeters above the rim in females.
      • Yalçınkaya E
      • Cingi C
      • Söken H
      • Ulusoy S
      • Muluk NB.
      Aesthetic analysis of the ideal eyebrow shape and position.

      Middle Face

      The middle face starts at the glabella superiorly and extends to the subnasale inferiorly. Attention should be given to the eyes/orbits, periorbital tissue, nose, zygoma, and malar soft tissue (Figure 2).
      Figure 2
      Figure 2Typical differences between the middle-third of the male and female face in A) frontal and B) lateral view, including the orbits, periorbital tissue, nose, and zygoma.
      Eye shape and intercanthal distance influence perceived gender identity. Female eyes have a more prominent appearance with a higher and narrower intercanthal distance.
      • Brown E
      • Perrett DI.
      What gives a face its gender?.
      ,
      • Dang BN
      • Hu AC
      • Bertrand AA
      • et al.
      Evaluation and treatment of facial feminization surgery: part I. forehead, orbits, eyebrows, eyes, and nose.
      Wider eyes in proportion to the face is associated with a more feminine and attractive face.
      • Tanikawa C
      • Zere E
      • Takada K.
      Sexual dimorphism in the facial morphology of adult humans: A three-dimensional analysis.
      Male eyes tend to have a wider intercanthal distance, narrower palpebral fissures, and be more deeply set relative to the plane of the face. Orbital differences between males and females come from mixed data, with some suggesting larger orbital width and height in males
      • Ferrario VF
      • Sforza C
      • Pizzini G
      • Vogel G
      • Miani A.
      Sexual dimorphism in the human face assessed by euclidean distance matrix analysis.
      ,
      • Ferrario VF
      • Sforza C
      • Pizzini G
      • Vogel G
      • Miani A.
      Sexual dimorphism in the human face assessed by euclidean distance matrix analysis.
      ,
      • Ghorai L
      • Asha ML
      • Lekshmy J
      • Rajarathnam BN
      • Mahesh Kumar HM
      Orbital aperture morphometry in Indian population: A digital radiographic study.
      and others indicating larger orbital aperture in females.
      • Dang BN
      • Hu AC
      • Bertrand AA
      • et al.
      Evaluation and treatment of facial feminization surgery: part I. forehead, orbits, eyebrows, eyes, and nose.
      ,
      • Tanikawa C
      • Zere E
      • Takada K.
      Sexual dimorphism in the facial morphology of adult humans: A three-dimensional analysis.
      ,
      • Velemínská J
      • Bigoni L
      • Krajíček V
      • et al.
      Surface facial modelling and allometry in relation to sexual dimorphism.
      Age and ethnicity may also affect these differences.
      • Ferrario VF
      • Sforza C
      • Pizzini G
      • Vogel G
      • Miani A.
      Sexual dimorphism in the human face assessed by euclidean distance matrix analysis.
      ,
      • Ghorai L
      • Asha ML
      • Lekshmy J
      • Rajarathnam BN
      • Mahesh Kumar HM
      Orbital aperture morphometry in Indian population: A digital radiographic study.
      Periorbital tissue includes the location of the supratarsal crease. In males, it sits lower than in females, but this varies according to ethnicity. The crease in white/Caucasian patients sits at an average of 10-12 mm above the lid margin in females and 7-8 mm in males. However, in Asian patients, the supratarsal crease may be lower or even absent.
      • Most SP
      • Mobley SR
      • Larrabee WF.
      Anatomy of the eyelids.
      Lower lid morphology does not appear to be significantly different between males and females.
      • Lakhiani C
      • Somenek MT.
      Gender-related Facial Analysis.
      ,
      • Most SP
      • Mobley SR
      • Larrabee WF.
      Anatomy of the eyelids.
      The nose has several aspects with specific features that differ between males and females, but these features vary considerably among different ethnicities. From a frontal view, the male nasal shape is long and wide due to wider nasal bones and dorsum, a higher nasion, and steeper nasal inclination.
      • Tanikawa C
      • Zere E
      • Takada K.
      Sexual dimorphism in the facial morphology of adult humans: A three-dimensional analysis.
      ,
      • Velemínská J
      • Bigoni L
      • Krajíček V
      • et al.
      Surface facial modelling and allometry in relation to sexual dimorphism.
      ,
      • Springer IN
      • Zernial O
      • Nölke F
      • et al.
      Gender and nasal shape: measures for rhinoplasty.
      The nasal base is also wider with greater interalar distance (3.5-3.8 cm) in males.
      • Springer IN
      • Zernial O
      • Nölke F
      • et al.
      Gender and nasal shape: measures for rhinoplasty.
      • Miranda GA
      • D'Souza M
      Evaluating the reliability of the interalar width and intercommissural width as guides in selection of artificial maxillary anterior teeth: A clinical study.
      • Smith BJ.
      The value of the nose width as an esthetic guide in prosthodontics.
      • Deogade SC
      • Mantri SS
      • Sumathi K
      • Rajoriya S.
      The relationship between innercanthal dimension and interalar width to the intercanine width of maxillary anterior teeth in central Indian population.
      The female nose is smaller vertically and transversely with a narrower interalar distance (3.2-3.4 cm).
      • Tanikawa C
      • Zere E
      • Takada K.
      Sexual dimorphism in the facial morphology of adult humans: A three-dimensional analysis.
      Some females tend to have a supratip break.
      • Springer IN
      • Zernial O
      • Nölke F
      • et al.
      Gender and nasal shape: measures for rhinoplasty.
      • Miranda GA
      • D'Souza M
      Evaluating the reliability of the interalar width and intercommissural width as guides in selection of artificial maxillary anterior teeth: A clinical study.
      • Smith BJ.
      The value of the nose width as an esthetic guide in prosthodontics.
      • Deogade SC
      • Mantri SS
      • Sumathi K
      • Rajoriya S.
      The relationship between innercanthal dimension and interalar width to the intercanine width of maxillary anterior teeth in central Indian population.
      On profile view, it is important to assess the nasofrontal angle, nasal dorsum, and nasal tip and rotation. Studies have indicated that the profile view has a more important role in gender identification compared to the frontal view.
      • Chronicle EP
      • Chan MY
      • Hawkings C
      • et al.
      You can tell by the nose–judging sex from an isolated facial feature.
      From a profile view, males have a narrower nasofrontal angle due to their more prominent glabellar projection and more anterior nasal tip projection (by up to 5 mm compared to the female nasal tip).
      • Dang BN
      • Hu AC
      • Bertrand AA
      • et al.
      Evaluation and treatment of facial feminization surgery: part I. forehead, orbits, eyebrows, eyes, and nose.
      Females have wider nasofrontal angle, relaxing the sudden transition between the forehead to the nose and leading to a softer overall appearance. In addition, the female nasal tip is less projected when compared with males, creating a less prominent profile. The dorsum of the male nose is flat or slightly convex whereas females have a narrower, more concave dorsum, though this is largely ethnicity-dependent.
      • Springer IN
      • Zernial O
      • Nölke F
      • et al.
      Gender and nasal shape: measures for rhinoplasty.
      Lastly, the nasolabial angle, which determines nasal tip rotation, is larger in females (105-108°) than in males (100-103°).
      • Bhat U
      • Peswani AR
      • Wagh S
      • Mishra R
      • Gupta T
      • Baliarsing A.
      Optimising Results of Nasal Tip Rotation Applying Combination of Nasolabial Angle and Lip-Columellar Angle in Tandem in Patients Operated by “Cock-up” Alar Cartilage Flaps Technique.
      Finally, the zygomatic arch varies between males and females. Males have a more pronounced zygomatic arch, with the point of maximal projection being higher and more lateral and having more extension inferiorly.
      • Schlager S
      • Rüdell A.
      Sexual Dimorphism and Population Affinity in the Human Zygomatic Structure—Comparing Surface to Outline Data.
      The cheek bone in females tends to be more accentuated due to prominent infraorbital cheek projection along with submalar hollowing.
      • Lakhiani C
      • Somenek MT.
      Gender-related Facial Analysis.
      ,
      • Tanikawa C
      • Zere E
      • Takada K.
      Sexual dimorphism in the facial morphology of adult humans: A three-dimensional analysis.
      ,
      • Velemínská J
      • Bigoni L
      • Krajíček V
      • et al.
      Surface facial modelling and allometry in relation to sexual dimorphism.

      Lower Face

      The lower face starts at the subnasale superiorly and extends to the chin inferiorly. The lips, jaw, and chin are part of the lower face (Figure 3).
      Figure 3
      Figure 3Typical differences between the lower-third of the male and female face in A) frontal and B) lateral view, including the lips, mandible, and chin.
      The shape, thickness, and volume of lips plays a role defining gender. The male lip shape is characterized by a thin upper lip and a small upper-to-lower lip ratio.
      • Ferrario VF
      • Rosati R
      • Peretta R
      • Dellavia C
      • Sforza C.
      Labial morphology: a 3-dimensional anthropometric study.
      The female upper lip is shorter transversely and taller vertically, leading to a fuller appearance of the lips. The Cupid's bow is more angulated with greater vermillion show in female upper lips.
      • Lakhiani C
      • Somenek MT.
      Gender-related Facial Analysis.
      ,
      • Ferrario VF
      • Rosati R
      • Peretta R
      • Dellavia C
      • Sforza C.
      Labial morphology: a 3-dimensional anthropometric study.
      The height-width ratio of the lower lip is similar between males and females.
      • Ferrario VF
      • Rosati R
      • Peretta R
      • Dellavia C
      • Sforza C.
      Labial morphology: a 3-dimensional anthropometric study.
      The mandible undergoes changes during puberty, but the growth rate is greater in males. The male mandible has a taller ramus, more prominent angle and lengthened body, and wider inter-ramus distance.
      • Fan Y
      • Penington A
      • Kilpatrick N
      • et al.
      Quantification of mandibular sexual dimorphism during adolescence.
      ,
      • Coquerelle M
      • Bookstein FL
      • Braga J
      • Halazonetis DJ
      • Weber GW
      • Mitteroecker P.
      Sexual dimorphism of the human mandible and its association with dental development.
      The height-width ratio of the mandible is greater in males. Compared to females, the lower jaw and chin of males can be nearly 20% longer.
      • Lakhiani C
      • Somenek MT.
      Gender-related Facial Analysis.
      ,
      • Tanikawa C
      • Zere E
      • Takada K.
      Sexual dimorphism in the facial morphology of adult humans: A three-dimensional analysis.
      The rectangular facial structure of males is due to (a) the broader mandible that extends steeply downward before it squares off at the basal symphysis and (b) larger masseteric attachments widening the jawline appearance. Females tend to have a heart or inverted pyramid-shaped facial structure due to a narrower and more rounded chin.
      • Fan Y
      • Penington A
      • Kilpatrick N
      • et al.
      Quantification of mandibular sexual dimorphism during adolescence.
      ,
      • Coquerelle M
      • Bookstein FL
      • Braga J
      • Halazonetis DJ
      • Weber GW
      • Mitteroecker P.
      Sexual dimorphism of the human mandible and its association with dental development.
      Dental malocclusion can impact the cephalometric relationships of the lower-third of the face.
      • Lakhiani C
      • Somenek MT.
      Gender-related Facial Analysis.

      Conclusion

      Fundamental understanding of core concepts in trans health are necessary for physicians and surgeons in order to provide conscientious and effective care to TGD patients. Particularly, an appreciation of proper patient communication, a framework for decision-making surrounding medical and surgical interventions, an awareness of obstacles surrounding healthcare, and a thorough understanding of facial anatomy are essential.

      Disclosure Statement

      The authors have no relevant conflicts of interest to disclose.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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