On Origins

The classification of individuals into dichotomous sex categories inevitably involves cultural work made possible by a history of definitional acts.

— STEVEN EPSTEIN, Inclusion, 2007

BEGINNING BEFORE THE BEGINNING

Douglas Ousterhout had just completed a general surgery residency at the University of Michigan when, in 1970, he packed up his life in Ann Arbor and moved to Palo Alto to begin a plastic surgery residency at Stanford University. "Before I started at Stanford," he explained, "I told them I didn't want to work with the gender program. I had heard what Don Laub was doing there, and I wasn't interested in working with transsexual patients." In the early 1970s virtually every plastic surgeon in the United States was aware of the new programs being established at universities across the country that were offering surgical services to a growing group of patients diagnosed as transsexual.

The first of these clinics opened at Johns Hopkins University in 1966, the year after Ousterhout graduated from medical school. Largely funded by private individual and institutional grants from the Erickson Educational Foundation, the Hopkins clinic served as an early model for the development of similar university-based clinics across North America, ushering in a brief period in the mid-1960s to late 1970s that the historian Susan Stryker (2008:93) has called "the 'Big Science' period of transgender history." Despite ongoing controversies among psychologists and medical doctors over what kinds of medical and surgical treatments should be offered to people newly understood to be suffering from transsexualism or gender dysphoria — if indeed any such treatments should be offered at all (Reay 2014) — at least a dozen university-based gender clinics were operating in the United States by 1979 (Restack 1979). Stanford University's Gender Dysphoria Program (GDP) opened in 1968 under the direction of Dr. Donald Laub, a plastic surgeon, and would prove to be one of the most influential programs in the country.

During his time as a plastic surgery resident at Stanford, Ousterhout's request to avoid working with Laub's GDP patients was granted, for the most part. He was never trained in the techniques used in genital sex-reassignment procedures — the operations most commonly associated with transsexual surgical interventions and for which Laub would become quite well known — but Ousterhout did see GDP patients in postoperative rounds and provided postsurgical care appropriate to his status as a resident. "I didn't have any real reason not to like them," he explained of the GDP patients. "I think that like most people at the time, I just didn't know anything about transsexuals, and I didn't really want to know." After leaving Stanford, Ousterhout turned his attention to craniofacial reconstructive surgery and thought his encounters with transsexual patients were behind him. But his connection to Stanford plastic surgery and the rapidly changing landscape of trans- medicine in the United States would bring trans- patients to his attention again nearly a decade later.

As quickly as they had been established, American gender clinics began to close down in the late 1970s. Despite its central role in the institutionalization of trans- medicine and the many technical innovations produced by its surgeons, the Stanford Gender Dysphoria Program closed its doors in 1980, when, like many chief surgeons in gender clinics around the country, Laub left academic medicine for private practice. (He continued to operate on trans- people as patients of Gender Dysphoria Program, Inc., now a private clinic located across the street from Stanford's campus.)

In 1982, two years after the Stanford program severed relations with the university, a former patient named Candace returned to see the surgeon who had performed her genital sex-reassignment surgery (GSRS) some years before. Despite the profound change that GSRS had enacted in her body and sense of self, Candace found that its transformative power was limited to her body alone. Though the fact of her restructured genitalia constituted her as a woman medically and legally, socially it made no change in her life at all. Like many women Candace had gone to great lengths to cultivate a desirably feminine body: she wore her hair long and well styled, and she made strategic choices in clothing and makeup. She had begun what would be a lifelong regimen of hormonal therapy, undergone electrolysis to remove her facial and body hair, and devoted considerable time to retraining her voice and comportment. Despite her best efforts, however, others still saw and reacted to her not as the woman she knew she was but as a man who was trying — but failing — to look like a woman. She endured insults and stares and felt the weight of disdain directed at those whose bodily presentations deviate from the norm. The fact of her new female genitalia — the bodily metonym of sex difference whose transformation is often believed to instantiate if not to define "sex change"— was secreted away behind the bounds of propriety in social life: no one knew it was there. But they did see her face. It was clear to Candace that her face was the problem. She had a man's face. No amount of makeup or decoration could hide it. She returned to her plastic surgeon, wondering if anything could be done. Her surgeon turned to Ousterhout.

By that time Ousterhout had established himself as a distinguished cranio-maxillofacial surgeon. After leaving Stanford years before, he completed a prestigious fellowship with the renowned craniofacial surgeon Paul Tessier in Paris and then returned to California, where he helped to found the Center for Craniofacial Anomalies at the University of California, San Francisco, Medical Center. Prior to Candace's request, Ousterhout had never thought about skulls as being male or female, masculine or feminine. "Here I had been operating at UCSFfor several years," Ousterhout explained, "and I had never thought about the differences between a boy's and a girl's skull." Ousterhout's work as a cranio-maxillofacial surgeon had been guided by the directive to make pathologically abnormal skulls and faces into "normal" ones. And up to that point "normal" had not been a sexed or gendered category.

Still ambivalent about working with transsexual patients, Ousterhout was intrigued by Candace's problem and drawn to the technical challenge her case presented. Treating her offered him the chance to do something new. Whatever technical skills might be necessary, the first step was a definitional one: at that point, as a surgical category, "the female face" did not yet exist.

This chapter begins with the story of how facial feminization surgery was developed in the early 1980s and ends with an accounting of how Ousterhout's FFS practice looked when I began working in his office in 2010. In the early years Ousterhout considered facial...