Coronavirus disease of 2019 (COVID-19) has drastically altered how we interact with each other. Video conferences and masking have increased focus on the upper facial third.1 In the transgender community, this increased focus on the face could have substantial effects on facial gender recognition, leading to exacerbation of facial gender dysphoria.2 Misgendering can compound the effects of transphobia experienced by this community, intensifying both discrimination and social isolation. With the increased challenges faced by the transgender community during the pandemic, including access to gender-affirming care and social support, worsening of gender dysphoria may have devastating outcomes.3
With worldwide quarantine requirements, limitations of domestic and international travel, and the necessity of personal protective equipment because of COVID-19, health care delivery has needed to adapt effectively and efficiently, especially in relation to gender affirmation.4 We have seen a substantial increase in online and personal consultations with people from around the world interested in facial feminization surgery. During our consultations, we noticed a rising trend: members of the transgender community reported increased episodes of being misgendered and attributed this to the use of facial masks or coverings. An important question arose: does wearing a facial mask accentuate aspects of the face that are generally considered more masculine?
Studies on facial gender recognition point to a variety of aspects of the face that influence gender perception.5 The gender markers of the middle and lower facial thirds are less influential behind a mask. In turn, because of facial coverings, attention is driven completely to eyes, brows, and hairline, converting the facial upper third into the main protagonist in facial gender recognition. The perception of this area has now become central to the interpretation of gender as a result of wearing masks.
Our research into how laypersons evaluate faces for gender markers supports these patient experiences. By using eye-tracking devices, we observed where people fixate and how they pattern their gazes on transgender women after facial feminization.6 The results indicate that the forehead region receives significant focus when people evaluate faces and that the bone structure of the forehead (frontal bone) is fundamental to facial gender recognition (Fig. 1).
;)
Fig. 1.: Clinical case before and after facial gender confirmation surgery. Procedures performed included forehead reconstruction by a coronal approach and rhinoplasty.
When using face masks, we are not only hiding a great deal of our faces, but we are driving attention and giving a greater role to the upper third of the face. Even if a person presents with feminine features of their middle and/or lower facial thirds, the use of a facial covering can exacerbate their facial gender dysphoria, as their feminine features are not accentuated when covered.
Forehead feminization surgery, when applied properly to appropriate patients, can have a substantial impact on the improvement of their gender dysphoria.7 No set of operations can eliminate masculinity of the upper third of the face, but interventions can improve feminine contour and oftentimes can play an important role in facial gender recognition.2
The face mask is essential during the COVID-19 pandemic. We are not advocating removal of masks to accentuate feminine features of the face; we are only noting the role masking has in highlighting the upper third of the face and how this potentially contributes to misgendering in the transfeminine community.
ACKNOWLEDGMENTS
The authors acknowledge their team, their families, and their patients.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
Daniel Simon, D.M.D.
Luis Capitán, M.D., Ph.D.
The Facialteam Group
HC Marbella International Hospital
Marbella, Málaga, Spain
Shanique A. Martin, M.D.
Division of Plastic Surgery
Department of Surgery
University of Washington School of Medicine
Seattle, Wash.
Rahim Nazerali, M.D., M.H.S.
Division of Plastic and Reconstructive Surgery
Department of Surgery
Stanford University
Palo Alto, Calif.
Thomas Satterwhite, M.D.
Align Surgical Associates
San Francisco, Calif.
Shane D. Morrison, M.D., M.S.
Section of Plastic Surgery
University of Michigan School of Medicine
Ann Arbor, Mich.
Fermín Capitán-Cañadas, Ph.D.
The Facialteam Group
HC Marbella International Hospital
Marbella, Málaga, Spain
REFERENCES
1. Chandawarkar A, Jenny H, Kim R. Data-driven insights on the effects of COVID-19 on aesthetics: Part I (passive analysis). Aesthet Surg J. 2021;41:NP65–NP74.
2. Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al. Prospective quality-of-life outcomes after facial feminization surgery: An international multicenter study. Plast Reconstr Surg. 2020;145:1499–1509.
3. van der Miesen AIR, Raaijmakers D, van de Grift TC. “You have to wait a little longer”: Transgender (mental) health at risk as a consequence of deferring gender-affirming treatments during COVID-19. Arch Sex Behav. 2020;49:1395–1399.
4. Asaad M, Rajesh A, Vyas K, Morrison SD. Telemedicine in transgender care: A twenty-first-century beckoning. Plast Reconstr Surg. 2020;146:108e–109e.
5. Morrison SD, Vyas KS, Motakef S, et al. Facial feminization: Systematic review of the literature. Plast Reconstr Surg. 2016;137:1759–1770.
6. Martin SA, Morrison SD, Patel V, et al. Social perception of facial feminization surgery outcomes: Does gender identity alter gaze? Aesthet Surg J. E-published December 18, 2020.
7. Capitán L, Simon D, Bailón C, et al. The upper third in facial gender confirmation surgery: Forehead and hairline. J Craniofac Surg. 2019;30:1393–1398.
GUIDELINES
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:
- Text—maximum of 500 words (not including references)
- References—maximum of five
- Authors—no more than five
- Figures/Tables—no more than two figures and/or one table
Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.
We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
