Description of sex difference as prescription for sex change: on the origins of facial feminization surgery.

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SSS0010.1177/0306312714531349Social Studies of Science X(X)Plemons

Article

Description of sex difference as prescription for sex change: On the origins of facial feminization surgery

Social Studies of Science 2014, Vol. 44(5) 657–679 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0306312714531349 sss.sagepub.com

Eric D Plemons

Society of Fellows and Department of Anthropology, University of Michigan, Ann Arbor, MI, USA

Abstract This article explores the research project that led to the development of facial feminization surgery, a set of bone and soft tissue reconstructive surgical procedures intended to feminize the faces of male-to-female trans- women. Conducted by a pioneering surgeon in the mid-1980s, this research consisted of three steps: (1) assessments of sexual differences of the skull taken from early 20thcentury physical anthropology, (2) the application of statistical analyses taken from late 20th-century orthodontic research, and (3) the vetting of this new morphological and metric knowledge in a dry skull collection. When the ‘feminine type’ of early 20th-century physical anthropology was made to articulate with the ‘female mean’ of 1970s’ statistical analysis, these two very different epistemological artifacts worked together to produce something new: a singular model of a distinctively female skull. In this article, I show how the development of facial feminization surgery worked across epistemic styles, transforming historically racialized and gendered descriptions of sex difference into contemporary surgical prescriptions for sex change. Fundamental to this transformation was an explicit invocation of the scientific origins of facial sexual dimorphism, a claim that frames surgical sex change of the face as not only possible, but objectively certain.

Keywords facial feminization surgery, physical anthropology, sex reassignment surgery, transsexual

Early surgical procedures intended to change a person’s sex focused on the genitals as the site of a body’s maleness or femaleness and took the reconstruction of these organs Corresponding author: Eric D Plemons, Society of Fellows and Department of Anthropology, University of Michigan, 101 West Hall, 1085 South University Avenue, Ann Arbor, MI 48109, USA. Email: [email protected]

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as the means by which ‘sex’ could be changed. Genital reconstructive surgery and endocrine interventions have remained at the center of both medical and popular imaginations in the matter of somatic sex change. However, in the mid-1980s a novel set of procedures was developed in order to change a part of the body that proponents claim plays a more central role in the assessment and attribution of sex in everyday life: the face. Facial feminization surgery (FFS) is a set of bone and soft tissue reconstructive surgical procedures intended to feminize the faces of male-to-female (MTF) trans-women.1 This growing contemporary practice is regularly performed by only six surgeons in the United States and a handful of other surgeons worldwide. The patient request that would lead to the development of FFS came in 1982, when plastic surgeon Dr Darrell Pratt2 approached Dr Douglas Ousterhout as a colleague asking for a favor. Candice, a male-to-female transsexual patient on whom Pratt had successfully performed genital sex reassignment surgery (GSRS), had returned to the clinic some months later with a new surgical request. Although GSRS had changed her sex both genitally and in profoundly personal ways, it had made exactly no impact on how others perceived her sex in everyday social life. The fact of her new female genitalia – the bodily site of sex difference whose transformation is often considered to instantiate, if not to define ‘sex change’ – was secreted away behind the bounds of propriety in social life. But people did see her face. It was clear to Candice that her face was the problem. She had a man’s face and no amount of make-up or decoration could hide it. She wondered whether anything could be done. Dr Douglas Ousterhout, in whose offices and operating rooms I conducted a year of ethnographic research between 2010 and 2011, is a cranio-maxillofacial surgeon who built a distinguished career reconstructing the faces and skulls of children and adults with severe injuries and congenital deformities. When Pratt first approached Ousterhout with the request that he feminize Candice’s face, Ousterhout had to figure out exactly what such a surgical reconstruction would entail, because at that point, as a surgical category, ‘the female face’, did not exist. ‘Here I had been doing surgery at [a major research hospital] for several years’, Ousterhout explained, ‘and I had never thought about the differences between a boy and girl’s skull’. As a reconstructive surgeon, Ousterhout’s work had been organized by the directive to make pathologically abnormal skulls and faces into ‘normal’ ones. Constituted as a corrective to the often devastating injuries and deformities that his surgical interventions were meant to correct, ‘normal’ had never been a sexed or gendered category. Rather than refusing Candice’s request on account of this uncertainty, Ousterhout set about trying to determine what constituted ‘masculine’ and ‘feminine’ as craniofacial categories. His research, as he explained it to me from behind the large desk in his personal office, involved three main steps. First, he consulted literature from early 20thcentury physical anthropology in order to identify sites in the facial skeleton that physical and forensic anthropologists had used to characterize sex differences in dry skulls. Second, he took those sites of differentiation and quantified them by applying a set of measurements derived from a longitudinal orthodontic cephalogram study. Finally, he used these newly acquired skills of distinction to evaluate a dry skull collection, with the aim of cultivating a new way of viewing skulls as distinctly sexed objects. He understood


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this proposed intervention as working within the logic of the larger transsexual surgical project: transsexual surgical interventions are intended to enact a change of sex. Thus, his research did not question whether there are significant sex differences in the facial skull, but rather what those differences were and how they could be surgically (re)constructed. In other words, he wanted to know how to clinically understand the maleness that he and others already recognized in Candice’s face and how to change it. Identifying ‘the female face’ out of the wide variety of human facial forms is no easy task; each step of this research required marshaling and reconciling forms of evidence that speak to each other only on the premise that ‘femaleness’ has an abiding and discernible form. Despite the constant work of definition that will be demonstrated below, it is the proposition that femaleness has a stable form that makes investigations about it simply different methodological attempts to triangulate the same ostensibly natural fact: women look different from men (Garfinkel, 1967; Kessler and McKenna, 1978). The most critical of the junctures in Ousterhout’s research occurred between steps 1 and 2, when the ‘feminine type’ of early 20th-century physical anthropology was made to articulate with the ‘female mean’ of 1970s’ statistical analysis. When the ‘type’ (a methodological tool that is general by definition) met the statistical mean (a methodological tool that fixes generality to a specific number), these two very different epistemological artifacts worked together to produce something new: a singular female skull with a stable and definable form, differing from the male skull in a standard set of ways. Once the typological distinction was stabilized by statistical analysis, it seemed not only to confirm the veracity of the type, but also to transform the type from what Daston and Galison (2007) have called a ‘reasoned image’, produced through and for interpretation, into an objective measurement collected by radiography and analyzed through complex computation. This translational move brought the ‘feminine type’ forward in time and across what I will term ‘epistemic styles’, following Ian Hacking (1992) and drawing on Hans-Jörg Rheinberger’s work (2010), transforming it from an historically troubled anthropological description of sex difference into a contemporary surgical prescription for sex change. This article explores the development of facial feminization surgery, querying along the way the sites and terms by which each of these research steps – involving very different logics of observation and measurement – were made to speak to each other, resulting in a single truth about sexual difference and, by extension, a surgical plan for accomplishing sex change. The ‘scientific basis’ that Ousterhout asserts for his work in FFS both reflects his therapeutic philosophy and does important rhetorical labor. By characterizing FFS as a ‘scientific’ undertaking, Ousterhout aligns it (and himself) with the therapeutic legitimacy of reconstructive sex-changing procedures, as opposed to surgery that responds to vanities (Gilman, 1998, 1999; Gimlin, 2010). To be sure, a thorough examination of FFS demands a consideration of its social, subjective, and political aspects. Here, by focusing on the history of FFS, I show how invocations of ‘science’ and ‘evidence’, legitimized through a series of methodological interventions, were critical to the emergence of a distinctively female face as an object of knowledge that was and continues to be used to ground surgical practice.


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Separate skulls What sets FFS apart from other, more commonly performed surgeries intended to feminize the face, such as facelifts or eyelid lifts, is its focus on the modification and reconstruction of facial bones as well as soft tissues. Bones provide the underlying structure to the face and in FFS discourse are the sites where essential claims to maleness and femaleness reside. While soft tissue changes are an essential part of FFS, the desired effect of ‘feminization’ is generally considered impossible to achieve through soft tissue procedures alone. Surgical discourse makes it clear that skulls are not neutral structures upon which sexually differentiated soft tissues are draped (cf. Schiebinger, 1987). Instead, it is the skull itself that provides the architecture of facial sex difference. Altering the soft tissues without changing the bony male characteristics beneath them would leave a patient looking ‘like a man with a facelift’, one patient told me emphatically. Although surgeons disagree about how much and what type of bone reconstruction is required in order to produce the effect of feminization – these points of disagreement constitute their individual approaches – all FFS specialists agree that some bone work must be done. When first searching for sexed distinctions of the facial skeleton, Ousterhout found no guidance from medical sources. Instead, he turned to a science for which the distinction of male and female bony structures had been a long-standing concern: physical anthropology. In the first surgical publication ever to describe the morphological characteristics of skulls with the express purpose of transforming their sexed distinctions, Ousterhout identified the key role of anthropological knowledge in the formulation of these procedures: Physical anthropologists and forensic pathologists are concerned with the identification and separation of skulls by sex. Prior to the computer and discriminant function analysis, these scientists primarily used three skeletal characteristics to separate the male from the female skull: the chin, the nose, and the forehead. (Ousterhout, 1987: 701)

He cited six sources to ground this claim: a book on forensic anthropology that identified aspects of the face frequently used to assign sex (Stewart, 1979); an article on the utility of facial modeling to identify the dead based on skeletal remains (Snow et al., 1970); and four articles on the use of discriminant function analysis to determine sex based on skeletal materials, mostly mandibles (Giles, 1964; Giles and Elliot, 1963; Stewart, 1954; Thieme and Schull, 1957). I want to note three important points from the above passage that will inform much of what is to follow. First, by identifying methods used before ‘the computer and discriminant function analysis’, Ousterhout dated and specified the forms of knowledge that were most helpful to his research. ‘Discriminant function analysis’ is a statistical operation used to identify the points of divergence in a given set of data that can most effectively be used to separate those data into a researcher’s predetermined groups. In the case of the articles cited above, researchers used skulls of known sex from established collections and measured a variety of features to determine which of those features most accurately placed that skull into one of two sex


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groups: male or female. This kind of statistical analysis was developed in the 1930s in articles describing the speciation of flowers (Fisher, 1936, 1938, 1940) – though their publication in Annals of Eugenics suggests interests in other kinds of speciation – and was first used to assign sex in physical anthropological research in the 1950s (Mukherjee et al., 1955; Pons, 1955). It did not come into widespread use until the late 1960s and 1970s when computers that could run these operations became widely available (Mays, 1998). Prior to the application of these statistical models, ‘traditional anthropological methods’ were based on the ‘art’ of ‘personal judgment’ (Hanna and Washburn, 1953: 27). It was these pre-computational methods of discernment from the early 20th century – the more artistic and subjective methods – that Ousterhout found useful. Second, physical anthropological texts from the early 20th century included many parts of the skull that could be used in assigning sex, some of which are at the back or base of the skull. Some of these features may be more reliably useful than facial features when assigning sex (Keen, 1950: 77), but they were not relevant to the craniofacial surgeon attempting to alter the social perception of the patient in the world. Ousterhout focused his attention on characteristics that he could change and that could be seen: the chin, nose, and forehead. Finally, Ousterhout called the physical anthropologists whose work he was using, ‘scientists’. I call attention to this identification not to dispute its legitimacy, but to highlight the rhetorical work accomplished by calling someone a scientist and thereby classifying his or her findings as scientific (e.g. Anderson, 1992). By pronouncing himself to be on the side of the scientific, Ousterhout safeguarded his claims to sexual difference from criticisms that often plague cosmetic surgeons: that the work they do is purely subjective, a reflection of shifting social norms and their own aesthetic tastes (cf. Gilman, 1998). The invocation and alignment with science and numbers also accomplished two related ends. First, it responded to a growing call for ‘evidence-based medicine’ that was gaining momentum in the early 1980s (Berg, 1995; Lambert, 2006; Schlich, 2007). Second, it helped to defend the emergence of FFS from institutional and professional debates about the merits of sex reassignment surgery that were raging at that time, precisely around the question of whether and how surgical sex reassignment had therapeutic value and what kinds of evidence were being used to justify its practice (Lothstein, 1982; Rudacille, 2005; Stryker, 2008). As a procedure based on ‘objective’ forms of evidence from anthropological scientists, FFS could draw on the legitimacy of reconstructive surgery, a form of intervention whose orientation toward producing desirably normal bodies had long been recognized as belonging to restorative and rehabilitative medicine, rather than a patient-initiated desire for ideal appearances. This distinction – between medical necessity and patient desire – was precisely the one around which the debates over the efficacy of sex reassignment were organized. Informed by and aiming for an objectively determined anatomical normalcy, FFS was poised as a practically and epistemologically valid response to the ‘condition’ of transsexualism whose diagnostic profile had been legitimized through codification in the Diagnostic And Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1980, just a few years before Candice arrived in Ousterhout’s office (American Psychiatric Association, 1980).


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The feminine type Early 20th-century physical anthropology was a resource for Ousterhout for the same reasons that it has been jettisoned by many contemporary physical anthropologists: the research done during this time depended explicitly on the judgment of individual practitioners and their assessments of sex based on the look of a skull. Investigations of sex difference – and many other things – during this period put the observer in a central position, because the cultivation of trained sight was understood as a critical tool of the trade (Hrdlička, 1939). Following World War II, these subjective practices, mired as they were in the histories of eugenic science, were supplanted in favor of a set of methods that foregrounded the objectivity promised by measurement (Armelagos and Van Gerven, 2003; Haraway, 1989). Describing what he sees as a fundamental epistemological transformation at the beginning of the 20th century, Hans-Jörg Rheinberger (2010) says, ‘[a] reflection on the relationship between concept and object from the point of view of the knowing subject was gradually replaced by a reflection of the relationship between object and concept that started from the object to be known’ (p. 3). In other words, this latter research paradigm focused more on the properties of skulls, rather than on the perceptions of the person studying them. This shift in epistemic styles is exemplified in Hanna and Washburn’s (1953) article in which they argued that measurement should replace the ‘art’ of ‘guessing’ in ‘traditional’ processes of sex determination: Traditionally, the sex of the bone would be guessed and then the measurements taken. By the method described in this paper, the measurements are taken first, the position of the specimen in the series is determined, and finally an estimate of the sex is given. The importance of the difference in procedure arises from two sets of factors. If sex is assigned first, then the measurements can do no more than quantify the opinion of the person who guessed the sex. The investigator may be right most of the time, but this can not be proved because all the observers biases are incorporated into the original sorting. (Hanna and Washburn, 1953: 26)

Measurement and objectivity were quickly taking the place of subjective assessments, but Ousterhout wanted to understand how certainty of sex could be derived from a look, for people would be reading Candice’s sex by looking at her face, not measuring it. When Ousterhout drew on early 20th-century anthropological descriptions of ‘the characteristics of the female face’, he was not only reaching back in time, but more importantly, he was reaching across epistemic styles. Working within a late 20th-century medico-scientific milieu that increasingly valued ‘clinically scientific’ (Gordon, 1988) and ‘evidence based medicine’ (Mykhalovskiy and Weir, 2004), Ousterhout found his foundational evidence in an artifact from an earlier scholarly moment, one that considered the relationship between researchers, bodies, and practice in much different terms. In order to name both the data and the epistemological status of this pre-War face, I argue that it is best understood as a feminine type. Types are, by definition, ideals clustered around a non-specific form. The typologizing project of early physical anthropology emerged from the legacy of 18th-century naturalism. This period that Daston and Galison (2007) have called ‘truth-to-nature’, characterizes a moment in scientific investigation and representation before objectivity


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was exalted as its highest virtue. It demanded that observation and measurement be tempered with what the researcher saw as the fundamental truths beneath the imperfections of any individual specimen. The truth-to-nature commitment to a ‘reasoned image’ was one that explicitly relied on the trained observer’s impression of an essential form, unmarred by the particularities of any one example of it. Like all types of natural phenomena that were created at this time – such as the better-studied racial type (Fabian, 2010; Russett, 1989; Schiebinger, 1993) and the criminal type (Gilman, 1985; Horn, 1995) – the ‘feminine type’ did not depend on the existence of any one particular form but was the product of a researcher’s experience of observation over time (Daston and Galison, 2007: 69). The feminine type was constituted, in large part, by scholars’ ideals of gendered beauty and desirability. Major philosophical and naturalist figures of the mid-19th century including Christoph Meiners, George Cuvier, and G.W.F. Hegel used notions of bodily beauty, especially in relation to the face and skull, as a proxy for establishing racial as well as gender types and their associated hierarchies (Isaac, 2004: 105–108). German medical doctor and anthropologist Johann Alexander Ecker brought the beautiful feminine type famously celebrated by Johann Blumenbach (Fabian, 2010; Thomas, 2001)3 forward to the late 19th century, adding to it the scientific sheen of the thenascendant practice of craniology. In 1868, Ecker, an Honorary Member of the London Anthropological Society who had amassed a significant collection of skulls (Orschiedt et al., 2011), published his craniological profile of males and females that characterized females as anatomical (and political) intermediaries between children and males (cf. Russett, 1989; Schiebinger, 1987). Ecker acknowledged that his ‘characteristic cranial profile’ did not apply to all females, but could most easily be found in ‘handsome women’. He went on to extol the virtues of this ideal and to describe the ‘handsome’ profile as constituting the very definition of the female: We need not be surprised that we do not find this female type equally pronounced in every head, just as little as we find in every male figure the masculine habitus. But that this form occurs so well pronounced in heads which we designate beautiful and womanly, proves that this form is typical for the female sex. (Ecker, 1868: 355)

The collapse of the categories of the feminine as recognized by the desired characteristics of handsomeness, beauty, and womanliness and of the female as biological category is a crucial one. Once it has been established that the best way to discern physical sex is through the evaluation of desirable gender traits then the project of sex assignment becomes an essentially social one (Fee, 1979). A skull’s legibility as female depends upon its recognition as desirably beautiful. As a type, then, the female is characterized, and thus the category itself is constituted, by its appealing beauty. It is, in part, through its inherent ability to appeal to and please the viewer’s sense of beauty that a skull becomes discernible as an instance of femaleness. This is as clear an example of performative sexing as any I have seen (Butler, 1990, 1993; Gere, 1999). This type that equated femaleness with a visually distinct gendered and aesthetic femininity persisted into the early 20th century. In his 1913 book Man and Woman, Havelock


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Ellis presented his impressions of the gendered characteristics of the face, understood as it often was, in terms of racial difference: On casual inspection women’s eyes seem to be generally larger and more prominent than men’s. This effect is for the most part apparent only, and is due to a large extent to the overarching of the bony ridges above the eyes in men. The races in whom this distinctively masculine character is deficient have an infantile or feminine appearance. (Ellis, 1913: 89–90)

Masculinity, here, takes on a very particular and racialized form, constituted by the presence of certain bony structures above the eyes. The absence of these structures results in ‘an infantile or feminine appearance’. Here, ‘feminine’ is the category of remainder; it encompasses the childlike, the womanly, and the racial groups that lack the prominent foreheads characteristic of Northern European males. Like many of his contemporaries (cf. Thomas, 1897), Ellis identifies femininity less in terms of its own properties than through lack: the feminine is what is left when the form of the masculine has been established. The words ‘feminine’ and ‘femininity’ were not adjectives used to describe female bodies but described the physically (and politically) diminutive status of the non-masculine. Invoking Petrus Camper’s facial angle, Ellis went on to write that while it is not the case among women of ‘the darker races in a lower stage of civilisation’, women of ‘European races’ have a tendency to alveolar prognathism (the bony ridges above and below their teeth have a slight forward prominence): This, although a savage character [in males], is far from being a defect; it frequently imparts, as Virchow remarks, a certain piquancy to a woman’s face. Perhaps the naïve forward movement of slight prognathism in a [white] woman suggests a face upturned to kiss; but in any case there is no doubt that while not a characteristic of high evolution it is distinctly charming. (Ellis, 1913: 91)

In its ‘piquancy’, the feminine form provokes the viewer, the viewer standing above her and looking down, drawing her face upward to kiss. This characteristic of the feminine type is one that follows on a long history of definition through the pleasing provocation of the male observer; it is a femininity that reflects particular preferences for attractiveness and ideal forms, while simultaneously confirming the lesser evolutionary status of ‘women’ and ‘savages’. Creating a catalog of ‘males are like x’ and ‘females are like y’ statements at the turn of the 20th century required that scholars ignore the proliferating data about the particularities of sexual difference across groups understood first as ‘races’ and then as ‘populations’ (cf. Haraway, 1989: 199–200, 1997: 248–249). While sex differences were acknowledged to vary in relation to population group4 and age, as an inexact form, the type was not burdened by these specificities; it was an ostensibly racially and age-neutral form. In the move to generalize sexed differences writ large, only one touchstone remained: the masculine face of the European male. Freed from the particulars of ageand population-based comparisons, the ‘feminine type’ became a means for explaining idealized sites and kinds of difference from the masculine norm. To be discernible as a


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type, ‘the feminine’ had to be significantly different from ‘the masculine’; sites of overlap and blurry borders could be discarded as unimportant variations on a central theme: typical men and typical women do not look alike. This kind of type persisted into the mid-20th century, unencumbered by age and population contingencies. In Aleš Hrdlička’s Practical Anthropometry (1939), we see the persistent generality of the feminine type and of the central role accorded to the viewer in its constitution. Hrdlička (1939) identified 12 sites of sexual differentiation in the human face and cranium. He summed up these points with an indicator he called the ‘physiognomy of the face’, ‘or the total impression that the face, especially with the lower jaw in position, makes upon the experienced observer’. The combination of many distinct features ‘gives the face a certain expression which is of great help in identifying the sex of the skull’ (p. 115). Put simply, the expectations of the researcher of the characteristics that constitute masculine and feminine appearances – or what founding figure of forensic anthropology Wilton Marion Krogman (1932) called a researcher’s ‘mental composite’ (quoted in Larnach, 1978: 25) – become tools for assigning sex. A skull that looks masculine to the researcher is likely male, and a skull that looks feminine is likely female. It is precisely this kind of typological data that Ousterhout found when he looked for visibly distinct gendered differences of the facial skull. Following World War II, physical anthropologists sought to distance themselves from research that depended so heavily on the ‘impressions’ of the ‘experienced observer’. The methods and products of this research so often directed at racial distinction (Hrdlička was a self-proclaimed eugenicist (Hrdlička, 1919; see also Blakey, 1987)) were seen in a decidedly different light once the practices and justifications of Nazi human experimentation became known. One important means of distinguishing postwar research from those studies done early in the 20th century was Sherman Washburn’s ‘New Physical Anthropology’, an approach that rejected ‘subjective’ research methodologies that produced ‘endless description’ (Armelagos and Van Gerven, 2003: 57) in favor of the ‘objective’ measurements of natural science (Hanna and Washburn, 1953; Haraway, 1989).5 This shift in epistemic style required not only a reconceptualization of the object of inquiry, but the refashioning of a distinct kind of scientific self (Daston and Galison, 2007).

The female mean Equipped with the specific sites in the facial skeleton where differences between the masculine and feminine types are most clearly manifest, Ousterhout next needed to quantify those differences in order to produce them surgically. Here, craniofacial sex difference became a problem of pragmatics. If the forehead (supraorbital bossing and frontal sinus) is smaller in females, how much smaller is it? If the chin height (from the tops of the bottom teeth to the inferior point of the chin) is smaller in females, how much smaller is it? Ousterhout’s personal experience led him to a source that could answer those questions. Prior to entering medical school, Ousterhout had earned a dental degree from the University of Michigan. During his tenure as a dental student, he worked as a research assistant on the University of Michigan Elementary and Secondary School Growth


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Study (UMGS), a longitudinal study of craniofacial growth that began in 1935. In 1974, the University of Michigan Center for Human Growth and Development published findings from this research in An Atlas of Craniofacial Growth: Cephalometric Standards from the University School Growth Study (Riolo et al., 1974). The Atlas contains ‘descriptive statistical information’ representing a series of measurements taken from the lateral cephalograms (profile radiographs of the head) of 83 individuals (47 males and 36 females). The ‘normal’ growth and form measured in the UMGS had no particular abnormal against which it was working; this was to be a keystone project that allowed other sorts of abnormalities to emerge as such. According to Dr James McNamara, the third author of the Atlas and respected researcher of craniofacial growth, the orthodontic interest in sexual dimorphism, then and now, is in estimating the ages at which male and female craniofacial bones stop growing. This information informs the timing and nature of orthodontic interventions. The fact that the UMGS Atlas produced a series of measurements describing the morphology of normal faces is somewhat external to its primary function but plays a significant role in the development and ongoing practice of Ousterhout’s facial feminization surgery. Like all of the children who were studied in major North American craniofacial growth research in the early part of the 20th century,6 the subjects of the UMGS were identified by their teachers and physicians as healthy, normally7 developing children. And they were all White.8 The research done on these several groups of school children constitutes the ‘normal face’ that continues to guide orthodontic practice. Concerns about repeated exposure to radiation involved in annually X-raying children’s heads halted these studies in the 1970s and has meant that no new longitudinal studies of this kind are being conducted today.9 Each page of the Atlas demonstrates the results of one set of measured variables. For example, one page may show the distance between two points and another the angle measuring the relation between two points. In the center of the page, tabulated data are given for male and female subjects listed by years of age from 6 to 16. Each row includes the sample size reported, the mean value at each age, and the standard deviation from the measured variable. At the bottom of the page, a graph shows the male and female mean values plotted against age. These graphs provide a visible rendering of the changes in skull shape and size during puberty. The sexually indistinguishable skulls of preadolescence can thus be seen to quite literally take shape across the plots of the individual graphs. Although the orthodontic interest in sexual dimorphism is not explained in the text, male and female categories organized the presentation of the research findings and were the values rendered visible through charts on each page. Judith Lorber (1994) has observed that study designs such as these ‘[r]arely question the categorization of their subjects into two and only two groups, even though they often find more significant within-group difference than between-group differences’ (p. 39). In fact, according to McNamara, within-group differences have never been calculated on these data. Any differences that may exist in this small pool are not visible in the Atlas, in any case. By providing only means and standard deviations, the statistical norming of measurements is total, making claims about sex difference ‘statements about differences between averages’ (Epstein, 2007: 249).


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Differences between the male and female groups were shown to exist in some instances, and not in others. But Ousterhout’s interest in sex-based comparisons in the Atlas was not a general one; he wanted to know how to quantify differences in the forehead, nose and chin, the sites that his research in physical anthropology had identified. The University of Michigan Elementary and Secondary School Growth Study (UMGS) Atlas provided the specificity of millimeters by which the feminine type could become a specific form, the female face. The data in this volume form the basis for Ousterhout’s measurement of ‘normal’ male and female ranges of craniofacial structures. A copy of this book was sitting on or near his desk during every day of my fieldwork in his office. Neon pink post-it notes had marked particular pages of the text for so long that their crumpled and exposed edges had faded to white. The numbers that define the female face do not simply guide Ousterhout’s surgical plan; they prescribe the values that must be accomplished in order to meet the burden of the ‘female’ face; they are the metrics of facial sex change. Before beginning an operation, I watched as he placed the patient’s frontal and lateral cephalograms on the operating-room light board. In the negative space of the cephalograms, post-it notes displayed three sets of numbers for each procedure he planned to perform: (1) the measurements he took of the patient’s skull in the presurgical exam; (2) the range of the female norm for each skeletal feature, as taken from the UMGS; and (3) the amount of reduction that is required to bring the patient into that normal range. Although the ‘female ranges’ were taken from the UMGS Atlas, it has been many years since Ousterhout has actually had to consult the book to find them. I watched him recite these figures from memory during patient exams, and jot them down without hesitation when preparing to enter the operating room. Once the patient’s skull has been measured, FFS becomes a problem of subtraction, and he knew the numbers by heart. When the vague relationality of the ‘feminine type’ was expressed as the statistically derived female mean – when Ousterhout’s method moved from deducing gender to inducing it – the general became specific and the identification of the feminine form no longer seemed as uncertain as the type itself would have it. Whereas the type was a form used to describe the visible distinctiveness of femininity, the mean was a number used to quantify the interior structural distinctiveness of the female. The aesthetic what one could subjectively see as the difference between masculine and feminine became the why one could see it in the objective terms of radiography and statistics. Although the type and the mean were both defined in relation to young, White faces – the feminine type was defined by its difference from the White masculine male, and the female mean was derived from measurements of White teenage girls – the ‘normal female face’ that emerges when the mean becomes the metrical expression of the type’s aesthetic contours obscures its own history (Canguilhem, 1978; Mol, 2002). At the end of the day, we have only two surgical categories: male and female. By stating as Ousterhout does his ability to move patients ‘from a male to a female’ through facial surgery, the complex relationship between ‘female’ and ‘feminine’ disappears. But even with this set of numbers, he still had to learn to see the sexed face in the way that Hrdlička and his contemporaries saw it: as a whole structure that gives a total effect of masculine or feminine.


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The certainty of hard skulls The final phase of Ousterhout’s foundational research took him to the Atkinson Library of Applied Anatomy, a private collection of approximately 1400 dry skulls housed at the Dugoni School of Dentistry. Spencer R. Atkinson (1886–1970), a dentist and orthodontist, personally assembled the collection over a 45-year period beginning in 1919 (Dechant, 2000). Through his own efforts and those of an extended network of friends and colleagues, Atkinson’s collection included skulls from Africa, Australia, Japan, China, and native peoples from North, Central, and South America (Pollock, 1969). The aggressive collecting practices and sheer number of individuals who contributed skulls to this collection in its early years meant that the kinds of provenance that typically accompany specimens in such collections are missing in many cases. It is for this reason that the Atkinson Library is classified as a ‘mixed collection’, one in which there is no distinction made between individuals of different population groups. For our purposes, the fact that the Atkinson Library is a mixed collection is important because physical anthropologists and archaeologists assert that assigning sex can be very difficult in this kind of sample.10 To the extent that human skulls can be described as sexually dimorphic, the characteristics of that dimorphism vary across population groups and with age (Sofaer, 2006). Dorothy Dechant, a physical anthropologist and current curator of the collection is reluctant to name the sex of specimens. ‘The best we can say is probably’, she told me in an interview. Even if one did not know the sex of the deceased, Dechant offered, one could line up a series of skulls to get a sense of the gradation in morphology that is typically understood to distinguish sex. In other words, one could literally assemble a line up stretching from masculine type on one end of the collection’s Styrofoam-covered table, to feminine type on the other. This is precisely what Ousterhout did. Just as Ecker pronounced the handsome and womanly skull to be female, so Ousterhout transformed the typically masculine and typically feminine skulls in the Atkinson collection into male and female ones. When Ousterhout visited the Atkinson Library in order to determine how the surgical project of producing female facial features might be undertaken, his interest was in seeing the structural constitution of male and female faces. Lacking definitive examples of those, however, the Atkinson collection did provide examples of typically feminine and masculine ones. What is crucial to see here is that ‘feminine’ skulls were not identified, because it is ‘feminine’ features that Ousterhout’s FFS patients desire. Rather, it is that ‘feminine’ skulls were performatively produced as female, and the fact of their femaleness was used to underwrite Ousterhout’s claim that he can surgically construct a skull whose distinction as female is rooted in its essential, biological properties. The gendered ideal of femininity became the fact of female sex – not only descriptively, but prescriptively as well. It was transformed from a look, an effect on the viewer, into the scientific evidence that would ground a surgical plan. Like those anthropologists whose typological project was oriented by mutual exclusivity, Ousterhout was interested in the extreme ends of the gendered scale. It was this form – the visibly feminine – that Candice wanted. The specificity of this desire as the extreme end of a range of possible forms is wholly absent from the discourse of natural and sexually dimorphic craniofacial difference that underwrites FFS. Certainty born of


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extreme opposition obscures the fact that the neat and mutually exclusive categories of male and female are artifacts of distinct moments when, through methodological and ideological interventions, the variety of human forms gives way to the supposed dichotomy of sexual difference. Claims to fundamental, oppositional difference are powerful, especially when they give material form to the desire to alter one sexed body in order to produce the other.

The persistence of the type in surgical literature and practice The female face that emerged as a result of this research process was quite a specific one, though its claims to efficacy and utility as a sex-changing model relied – and continues to rely – upon its presentation as the form of generalized, scientifically derived human craniofacial sex difference. The particular histories and contingencies in the forms of evidence from which it emerged have disappeared completely from the scene; they are absorbed by the surgical claims that opened this essay: there are anthropological differences between the faces of men and women. Part of what accounts for the persistence and persuasion of these claims is the assumed stability of the female face as a fact of the human body across time and place; as a cultural product, gender may change, but as a biological reality, sex does not. Through this series of methodological interventions, authorized as they were by an abiding belief that the face can be understood and reproduced as a sexually dimorphic body part, Ousterhout succeeded in turning the ‘feminine type’ into a prescription for surgical sex change. His formulation of the problem of FFS has been long-lasting, and his contributions are widely recognized in this small field of expertise (Altman, 2012; Becking et al., 2007; Bowman and Goldberg, 2006; Davidson et al., 2000; Dempf and Eckert, 2010; Habal, 1990; Hage et al., 1997; Hoenig, 2011; Spiegel, 2011; Vázquez and Vila, 2006). The application of statistical measurements transformed the feminine type from an aesthetically driven idealized version of what young, White women should look like, into a biological category used to describe what females do look like. It is the generalized and idealized feminine type, authorized by anthropological knowledge and objectivized through statistics, that enters surgical practice. While contemporary physical anthropologists and archaeologists recognize the sites of sex distinction that Ousterhout targets as characterizing general differences between sexes, the idea that one would take these general differences and quantify them metrically without consideration for population and age is troubling. When Ousterhout does so, he brings the discredited typological practice forward in time and across epistemic styles, effectively re-authorizing it as a fact of biological form. Masculine and feminine types appear in surgical literature to demonstrate sexed differences in the skull. Visual representation of dichotomous craniofacial sex plays a crucial role in communicating both the grounds for FFS and the sorts of interventions undertaken in its name. The use of radical contrast to identify the characteristics of skulls labeled ‘male’ and ‘female’ – rather than masculine and feminine – not only communicates simplified notions of these categories but also serves to help patients imagine the


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Figure 1. Male and female jaw structure as represented in Ousterhout’s brochure, ‘Feminization of the Transsexual’.

profound differences that bone reconstruction can produce. The images in Figures 1 and 2 appear in Dr Ousterhout’s self-produced brochure entitled Feminization of the Transsexual. This brochure, intended to educate patients, includes descriptions of the various procedures used in FFS alongside ‘anthropological’ explanations for their necessity. The adoption of typological representations of sex difference appears in professional surgical texts on FFS produced by other surgeons as well. The images in Figures 3 and 4 were included in a 1990 article on contouring the facial bones in FFS. The authors intend the image in Figure 3 to communicate the ‘anthropological differences between male and female’. In addition to the pronounced difference in facial features – one hooked, lined, and slanted while the other has virtually no discernible facial features at all – this image relies upon and helps to reproduce a number of assumptions about appropriate and exemplary bodies. Middle class and distinctly White gender markers take the place of labels in communicating which of these persons is supposed to demonstrate male features and which female. Their ability to stand as examples of male and female anatomical structures is predicated on their legibility as gendered persons. From cues given through hairstyles and dress, we are to first assign a sex to these figures and then observe the differences in their facial structures. Figure 4 goes even further in its depiction of the relationship between internal anatomical structure and the manifestation of that structure on the gendered body. This drawing depicts ‘steps in the operative procedure that changes facial contour from male to female’. Mirroring the male-on-left, female-on-right composition of Figure 3, this image shows a skull that is presumably half male and half female. The male half of the skull is left unmarked, while the signs of femaleness are produced not through an alteration of the bony structure – it is this fundamental difference and intervention that the authors claim this image represents – but by adorning the skull with gendered markers of femininity. The coiffed hair, petite nose, full lips, and accentuated eye seem to spring directly from the skull itself, as though the production of a ‘female contour’ could not help but produce these visible markers of femininity. In addition to thoroughly gendering


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Figure 2. Male and female craniofacial structure given in profile in Ousterhout’s ‘Feminization of the Transsexual’.

and racializing claims to fundamental anatomical differences, this image establishes the male skull as the fundamental form (cf. Schiebinger, 1993: 152–156) from which femaleness can be derived or, in this case, appended.

Conclusion There is no doubt that the story of the development of FFS is an idiosyncratic one. The same patient request made to a different surgeon may have led to a different path and any resulting version of FFS that emerged would likely have relied on other kinds of grounding forms. Indeed, contemporary surgeons who specialize in FFS see and intervene in their patients’ faces in ways that diverge from Ousterhout’s prescriptions. Discrepancies in therapeutic approaches reflect, among other things, the market dynamics of this specialty, in which differences in approach and technical style constitute points of competitive distinction. While Ousterhout’s practice has changed somewhat over time, modulated by the appealing harmonic ratios of the golden mean, patient feedback, and his own aesthetic tastes, at the heart of his practice remains a claim to the scientific basis of his work. Because faces are not easily recognized as sexually dimorphic in the way that genitals often are, framing facial reconstruction as a sex-changing procedure requires rhetorical labor. Ousterhout’s turn to ‘science’ and ‘numbers’ is an important means through which this work is done. By stabilizing male and female faces as anatomically distinct, rather than subjectively distinguishable, Ousterhout is able to frame his FFS operations


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Figure 3. Anthropological differences between male and female,’ as represented in Habal (1990:144).

as oriented to the same kind of ‘normal’ outcomes that guide his other reconstructive procedures. Preoperatively, his patients are normally male – a reality to which their experiences of social exclusion can often quite painfully attest – and postoperatively they will be normally female. This understanding of what FFS aims to do is set in explicit contrast to the frequent interpretation that it is simply a trans-specific variation on cosmetic surgery. Such a framing not only threatens the therapeutic and medical legitimacy of FFS as a sex-changing intervention, it also paints FFS surgeons undesirably as peddlers of a misogynist myth of feminine perfection (Talley, 2011). According to the patients and surgeons with whom I worked, interpreting FFS as a cosmetic procedure leads to misunderstanding of its aim and efficacy. Rather than producing a change in degree – from less beautiful to more beautiful or from old to young – FFS effects a change in kind by reflecting the fundamental form of males and females whose distinctiveness as natural kinds is measurable and observable through the ostensibly objective and value-neutral methods of biology and anatomy. In his account of the means by which medicine was transformed from a practice to a science in the postwar period, Marc Berg (1995) argues that by the early 1980s, ‘science’ stood as the salvific answer to a medical practice seen as idiosyncratically derived from


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Figure 4. Images taken from a surgical article on the feminization of the facial bones (Habal, 1990: 144–145).

clinicians’ own judgments. While cosmetic surgery is widely regarded as trend-driven and subjectively derived from the judgments of patients and surgeons, the therapeutic legitimacy of reconstructive surgery comes from its orientation to restore health through producing anatomically normal forms. Leveraging statistics as ‘social technologies’ that, as Ted Porter (1995) has argued, ‘must be understood as responses to problems of trust’ (p. 209), Ousterhout locates the anatomical certainty of the female face outside of himself, and thus firmly within the treatment logic of trans- medicine, a set of therapeutic interventions premised upon the idea that male and female forms can be both reliably assessed and surgically reproduced. Ousterhout’s claim to science and objectivity is one that matters to the patients who seek his services. They want to know for certain that the surgery – for which they will spend tens of thousands of dollars – will accomplish its stated aim. Reflecting the bodily logics and increasingly recognized ‘medical necessity’ of genital sex reassignment, patients reproduce Ousterhout’s claims that facial structures are as reliably dichotomous as genital structures and that changing them, therefore, constitutes a therapeutic change of sex.


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Ousterhout’s ‘female face’, rendering equal as it does the feminine type with the female mean, is a kind of ‘factish’ (Latour, 2010), one that holds within it a complex history in which the epistemologically mired claims to the bony skeleton as the form of social difference and the fetish of racialized and gendered beauty cannot be separated, in which forms of knowledge and value about the real body commingle and coproduce. Tracing the means by which ‘the female face’ emerged as an object that could ground the growing practice of FFS, we can consider these medico-surgical interventions into the gendered, and more specifically, the trans- body, as problems of historically specific forms of knowing and intervening. Deriving power and legitimacy by insisting on the objectivity of science in naming a distinctively female form, the origins of FFS were guided as much by a desire to meet a burden for medical practice as they were by the goal of making patients recognizable to themselves and others as women. While the procedures employed in efforts to make trans-women ‘look like women’ are undoubtedly products of gendered ideologies, so are they artifacts of research reflecting the conditions of the epistemic styles from which they emerge, as well as the convictions and experiences of individual surgeons who apply them (Plemons, 2014). The origin story of FFS has something to tell us about the history of physical anthropology, about race in the development of craniofacial and orthodontic growth standards, and about the precariousness of the boundaries between the natural body and its many constitutive outsides. It is also a story of knowledge across time, about looking for a look, and knowing it when you see it. Acknowledgements I would like to thank Cori Hayden, Charis Thompson, Lawrence Cohen, Theresa MacPhail, Katie Hendy, and four anonymous reviewers for their helpful comments on earlier drafts of this article. My thanks, too, to Sergio Sismondo for his close reading, direction, and feedback. I am grateful to the Michigan Society of Fellows for providing friendship, collegiality, and institutional support of my writing and research.

Funding This project was funded in part by a Dissertation Fieldwork Grant from Wenner-Gren Foundation and a Dissertation Year Fellowship from the UC Berkeley Center for the Study of Sexual Cultures.

Notes 1. A note on the use of trans- : Whereas Stryker, Currah and Moore (2008) use the term trans- in order to leave open the possibility of kinds of crossing that are not limited to gender, here I use it in order to draw attention to the multiple gendered endings to the word trans that have come to hold important personal and political stakes for those who use this word to identify themselves. Some people who seek FFS do so as part of their identities as transgender or transsexual people, while others feel these categories are too limited. Trans- leaves this space open. 2. Pseudonym. 3. Historian Nell Irvin Painter (2010) has noted that the ‘Georgian woman’ was an enduring example of beauty that circulated throughout travel and nature writing at this time. Blumenbach’s beautiful skull was codified as the exemplary White female form not only in


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4. 5. 6.

7.

8.

9.

his own writings but in Samuel Thomas von Soemmering’s influential early illustrations of the skeleton as well (Schiebinger, 1987). For example, Barnard (1935), Hooten (1930), and Parsons and Keene (1919). In spite of this, Armelagos et al. (1982) argue that ‘[m]ultivariate analysis has not eliminated typological thinking’ (p. 313). The University of Michigan Elementary and Secondary School Growth Study (UMGS) is one of ‘nine of the eleven known collections of longitudinal craniofacial growth records in the United States and Canada’ included in the American Association of Orthodontists Foundation (AAOF) Legacy Collection (http://www.aaoflegacycollection.org/aaof_home.html (accessed 5 May 2010)). For the purposes of the study, ‘normal’ meant only that these were students enrolled in the mainstream school and does not assume any representativeness of the larger population. This designation reflects language adopted across research on children at this time, which was spurred by President Hoover. There is much to say about which children might thus be counted as normal and which left out of such a designation, but that falls outside the scope of this article. A few small studies using cephalometrics were done to assess racial difference in the later 20th century (Alexander and Hitchcock, 1978; Altemus, 1960; Drummond, 1968; Richardson, 1980). For an early discussion of the problem of applying ‘The White Standards’ to other groups, see Cotton et al. (1951). The only longitudinal craniofacial growth study ever done on non-White children in the United States was conducted by Dr Elisha Richardson at Meharry Medical College in Nashville. Richardson published the findings of his 20-year-long study on African-American children in 1991. In the foreword to the volume, Dr Robert Moyers, a one-time director of the Michigan Center for Human Growth and Development, wrote: One of the most significant problems associated with the use of radiographic cephalometrics to characterize normal craniofacial growth is the fact that researchers have relied exclusively in the past on analysis of Western Europeans or of Americans of European descent for serial studies. Thus, the potential for bias insofar as characterization of the normal parameters of variability in [sic] craniofacial growth is concerned may be great. (Richardson, 1991: viii)

The unmarked whiteness of the normal form presented in the University School Growth Study Atlas reflects the absence of concern for racial difference, although many contemporary orthodontic researchers were interested in morphological differences based on race. 10. Techniques that do not rely on morphometrics, such as molecular genetic analysis, can be used to assign sex to osteological material. Because researchers who use the Atkinson Library have not been interested in this aspect of its holdings, such analyses have not been conducted. These kinds of ‘invisible’ evidence of maleness or femaleness were similarly unimportant to Ousterhout, who had identified feminine and masculine forms before arriving at the Atkinson Library.

References Alexander TL and Hitchcock HP (1978) Cephalometric standards for American Negro children. American Journal of Orthodontics 74(3): 298–304. Altemus LA (1960) A comparison of cephalofacial relationships. The Angle Orthodontist 30(4): 223–240. Altman K (2012) Facial feminization surgery: Current state of the art. International Journal of Oral and Maxillofacial Surgery 41(8): 885–894.


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American Psychiatric Association (1980) Diagnostic and statistical manual of mental disorders (3rd ed., text rev.). Arlington, VA: American Psychiatric Publishing. Anderson W (1992) The reasoning of the strongest: The polemics of skill and science in medical diagnosis. Social Studies of Science 22(4): 653–684. Armelagos GJ and Van Gerven DP (2003) A century of skeletal biology and paleopathology: Contrasts, contradictions, and conflicts. American Anthropologist 105(1): 53–64. Armelagos GJ, Carlson DS and Van Gerven DP (1982) The theoretical foundations and development of skeletal biology. In: Spencer F (ed.) A History of American Physical Anthropology 1930–1980. New York: Academic Press, pp. 305–328. Barnard MM (1935) The secular variations of skull characters in four series of Egyptian skulls. Annals of Eugenics 6(4): 352–371. Becking AG, Tuinzing DB, Hage JJ and Gooren LJG (2007) Transgender feminization of the facial skeleton. Clinics in Plastic Surgery 34(3): 557–564. Berg M (1995) Turning a practice into a science: Reconceptualizing postwar medical practice. Social Studies of Science 25(3): 437–476. Blakey ML (1987) Skull doctors: Intrinsic social and political bias in the history of American physical anthropology with a special reference to the work of Alěs Hrdlička. Critique of Anthropology 7(2): 7–35. Bowman C and Goldberg J (2006) Care of the Patient Undergoing Sex Reassignment Surgery. Vancouver, BC, Canada: Vancouver Coastal Health, Transcend Transgender Support & Education Society, and The Canadian Rainbow Health Coalition. Butler J (1990) Gender Trouble. New York: Routledge. Butler J (1993) Bodies That Matter: On the Discursive Limits of ‘sex’. New York: Routledge. Canguilhem G (1978) The Normal and the Pathological (trans. CR Fawcett). Boston, MA: D. Reidel Pub. Co. Cotton WN, Takano WS and Wong WMW (1951) The Downs analysis applied to three other ethnic groups. The Angle Orthodontist 21(4): 213–220. Daston L and Galison P (2007) Objectivity. New York: Zone Books. Davidson SP, Clifton MS, Futrell W, Priore R and Manders EK (2000) Aesthetic considerations in secondary procedures for gender reassignment. Aesthetic Surgery Journal 20(6): 477–481. Dechant D (2000) Our best kept secret: The Spencer R. Atkinson Library of Applied Anatomy. Contact Point: The Alumni Magazine of the Dugoni School of Dentistry 80(3): 15–19. Dempf R and Eckert AW (2010) Contouring the forehead and rhinoplasty in the feminization of the face in male-to-female transsexuals. Journal of Cranio-Maxillofacial Surgery 38(6): 416–422. Drummond RA (1968) A determination of cephalometric norms for the Negro race. American Journal of Orthodontics 54(9): 670–682. Ecker JA (1868) On a characteristic peculiarity in the form of the female skull, and its significance for comparative anthropology. Anthropological Review 6(23): 350–356. Ellis H (1913) Man and Woman: Study of Human Secondary Sexual Characters. New York: The Walter Scott Publishing Company Ltd. Epstein S (2007) Inclusion: The Politics of Difference in Medical Research. Chicago, IL: The University of Chicago Press. Fabian A (2010) The Skull Collectors: Race, Science, and America’s Unburied Dead. Chicago, IL: The University of Chicago Press. Fee E (1979) Nineteenth-century craniology: The study of the female skull. Bulletin of the History of Medicine 53(3): 415–433. Fisher RA (1936) The use of multiple measurements in taxonomic problems. Annals of Eugenics 7(2): 179–188.


677

Plemons

Fisher RA (1938) The statistical utilization of multiple measurements. Annals of Eugenics 8(4): 376–386. Fisher RA (1940) The precision of discriminant functions. Annals of Eugenics 10(1): 422–429. Garfinkel H (1967) Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice Hall. Gere C (1999) Bones that matter: Sex determination in paleodemography 1948–1995. Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 3(4): 455–471. Giles E (1964) Sex determination by discriminant function analysis of the mandible. American Journal of Physical Anthropology 22(2): 129–135. Giles E and Elliot O (1963) Sex determination by discriminant function analysis of crania. American Journal of Physical Anthropology 21(1): 53–68. Gilman SL (1985) Difference and Pathology: Stereotypes of Sexuality, Race, and Madness. Ithaca, NY: Cornell University Press. Gilman SL (1998) Creating Beauty to Cure the Soul: Race and Psychology in the Shaping of Aesthetic Surgery. Durham, NC: Duke University Press. Gilman SL (1999) Making the Body Beautiful: A Cultural History of Aesthetic Surgery. Princeton, NJ: Princeton University Press. Gimlin D (2010) Imagining the other in cosmetic surgery. Body & Society 16(4): 57–76. Gordon DR (1988) Clinical science and clinical expertise: Changing boundaries between art and science in medicine. In: Lock M and Gordon D (eds) Biomedicine Examined. Dordrecht: Kluwer Academic Publishers, pp. 257–295. Habal MB (1990) Aesthetics of feminizing the male face by craniofacial contouring of the facial bones. Aesthetic Plastic Surgery 14(2): 143–150. Hacking I (1992) ‘Style’ for historians and philosophers. Studies in History and Philosophy of Science Part A 23(1): 1–20. Hage JJ, Vossen M and Becking AG (1997) Rhinoplasty as part of gender-confirming surgery in male transsexuals: Basic considerations and clinical experience. Annals of Plastic Surgery 39(3): 266–271. Hanna RE and Washburn SL (1953) The determination of the sex of skeletons, as illustrated by a study of the Eskimo pelvis. Human Biology 25(1): 21–27. Haraway D (1989) Primate Visions: Gender, Race, and Nature in the World of Modern Science. New York: Routledge. Haraway DJ (1997) Modest_Witness@Second_Millenium.FemaleMan©_Meets_OncoMouseTM: Feminism and Technoscience. New York: Routledge. Hoenig JF (2011) Frontal bone remodeling for gender reassignment of the male forehead: A gender-reassignment surgery. Aesthetic Plastic Surgery 35(6): 1043–1049. Hooten EA (1930) The Indians of Pecos Pueblo: A Study of Their Skeletal Remains. Andover, MA: Phillips Academy. Horn DG (1995) This norm which is not one: Reading the female body in Lombroso’s anthropology. In: Terry J and Urla J (eds) Deviant Bodies: Critical Perspectives on Difference in Science and Popular Culture. Bloomington, IN: Indiana University Press, pp. 109–128. Hrdlička A (1919) Physical Anthropology: Its Scope and Aims; Its History and Present Status in the United States. Philadelphia, PA: The Wistar Institute of Anatomy and Biology. Hrdlička A (1939) Practical Anthropometry. Philadelphia, PA: The Wistar Institute of Anatomy and Biology. Isaac B (2004) The Invention of Racism in Classical Antiquity. Princeton, NJ: Princeton University Press. Keen JA (1950) A study of the differences between male and female skulls. American Journal of Physical Anthropology 8(1): 65–80.


678


Kessler SJ and McKenna W (1978) Gender: An Ethnomethodological Approach. Chicago, IL: The University of Chicago Press. Krogman WM (1932) The morphological characters of the Australian skull. Journal of Anatomy 66(3): 399–413. Lambert H (2006) Accounting for EBM: Notions of evidence in medicine. Social Science & Medicine 62(11): 2633–2645. Larnach SL (1978) Australian Aboriginal Craniology (The Oceania Monographs, vol. 21, issue 1). Sydney, NSW, Australia: The University of Sydney. Latour B (2010) On the Modern Cult of the Factish Gods. Durham, NC: Duke University Press. Lorber J (1994) Paradoxes of Gender. New Haven, CT: Yale University Press. Lothstein L (1982) Sex reassignment surgery: Historical, bioethical and theoretical issues. American Journal of Psychiatry 139(4): 417–426. Mays S (1998) The Archaeology of Human Bones. New York: Routledge. Mol A (2002) The Body Multiple: Ontology in Medical Practice. Durham, NC: Duke University Press. Mukherjee R, Rao CR and Trevor JC (1955) The Ancient Inhabitants of Jebel Moya Sudan. Cambridge: Cambridge University Press. Mykhalovskiy E and Weir L (2004) The problem of evidence-based medicine: Directions for social science. Social Science & Medicine 59(5): 1059–1069. Orschiedt J, Wittwer-Backofen U and Flohr S (2011) Germany/Deutschland. In: Márquez-Grant N and Fibiger L (eds) The Routledge Handbook of Archaeological Human Remains and Legislation. New York: Routledge, pp. 165–172. Ousterhout DK (1987) Feminizing of the forehead: Contour changing to improve female aesthetics. Plastic and Reconstructive Surgery 79(5): 701–713. Painter NI (2010) The History of White People. New York: W. W. Norton & Company, Inc. Parsons FG and Keene L (1919) Sexual differences in the skull. Journal of Anatomy 54(1): 58–65. Plemons ED (2014) It is as it does: Genital form and function in sex reassignment surgery. Journal of Medical Humanities 35(1): 37–55. Pollock HC (1969) The Atkinson Library of Applied Anatomy. American Journal of Orthodontics 55(5): 510–515. Pons J (1955) The sexual diagnosis of isolated bones of the skeleton. Human Biology 27(1): 12–21. Porter TM (1995) Trust in Numbers: The Pursuit of Objectivity in Science and Public Life. Princeton, NJ: Princeton University Press. Rheinberger H-J (2010) On Historicizing Epistemology: An Essay (trans. D Fernbach). Palo Alto, CA: Stanford University Press. Richardson ER (1980) Racial differences in dimensional traits of the human face. The Angle Orthodontist 50(4): 301–311. Richardson ER (1991) Atlas of Craniofacial Growth in Americans of African Descent. Ann Arbor, MI: Center for Human Growth and Development, University of Michigan. Riolo M, Moyers RE, McNamara JA and Hunter WS (1974) An Atlas of Craniofacial Growth. Ann Arbor, MI: Center for Human Growth and Development, University of Michigan. Rudacille D (2005) The Riddle of Gender: Science, Activism, and Transgender Rights. New York: Pantheon Books. Russett CE (1989) Sexual Science: The Victorian Construction of Womanhood. Cambridge, MA: Harvard University Press. Schiebinger L (1987) Skeletons in the closet: The first illustrations of the female skeleton in eighteenth-century anatomy. In: Gallagher C and Laqueur T (eds) The Making of the Modern Body: Sexuality and Society in the Nineteenth Century. Berkeley, CA: University of California Press, pp. 42–82.


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Schiebinger L (1993) Nature’s Body: Gender in the Making of Modern Science. Boston, MA: Beacon Press. Schlich T (2007) The art and science of surgery: Innovation and concepts of medical practice in operative fracture care, 1960s–1970s. Science, Technology & Human Values 32(1): 65–87. Snow CC, Gatliff BP and McWilliams KR (1970) Reconstruction of facial features from the skull: an evaluation of its usefulness in forensic anthropology. American Journal of Physical Anthropology 33(2): 221–227. Sofaer JR (2006) The Body as Material Culture: A Theoretical Osteoarchaeology. Cambridge: Cambridge University Press. Spiegel JH (2011) Facial determinants of female gender and feminizing forehead cranioplasty. The Laryngoscope 121(2): 250–261. Stewart TD (1954) Sex determination of the skeleton by guess and by measurement. American Journal of Physical Anthropology 12(3):385–392. Stewart TD (1979) Essentials of Forensic Anthropology: Especially As Developed in the United States. Springfield, IL: Charles C. Thomas. Stryker S (2008) Transgender History. Berkeley, CA: Seal Press. Stryker S, Currah P and Moore, LJ (2008) Introduction: Trans-, Trans, or Transgender? Women’s Studies Quarterly 36(3/4): 11–22. Talley HL (2011) Facial feminization and the theory of facial sex difference: The medical transformation of elective intervention to necessary repair. In: Fischer JA (ed.) Gender and the Science of Difference: Cultural Politics of Contemporary Science and Medicine. Piscataway, NJ: Rutgers University Press, pp. 189–204. Thieme FP and Schull WJ (1957) Sex determination from the skeleton. Human Biology 29(3): 242–273. Thomas DH (2001) The Skull Wars: Kennewick Man, Archaeology and the Battle for Native American Identity. New York: Basic Books. Thomas WI (1897) On a difference in the metabolism of the sexes. American Journal of Sociology 3(1): 31–63. Vázquez IM and Vila PM (2006) La cirugía de reasignación sexual de hombre a mujer. Cuadernos de Medicina Psicosomatica y Psiquiatria de Enlace 78: 30–39.

Author biography Eric D Plemons is Assistant Professor of Anthropology at the University of Michigan and a Postdoctoral Fellow of the Michigan Society of Fellows. His work has been published in Journal of Medical Humanities and The Body Reader: Essential Cultural and Social Readings (NYU Press).


Sex difference and the mind.

Sex ratio, sex change, and natural selection.

Surgery for sex reassignment.

Sex reassignment surgery for transsexuals.

Sex First-A New View of the Origins of Eukaryotes.

Sex differences in the developmental origins of cardiovascular disease.

Abandoning sex: multiple origins of asexuality in the ciliate Tetrahymena.

Same-sex marriage--a prescription for better health.

Facial Feminization Surgery: The Forehead. Surgical Techniques and Analysis of Results.

Reply: Facial Feminization Surgery: The Forehead. Surgical Techniques and Analysis of Results.

Fundamental sex difference in human brain architecture.

Sex difference in the phospholipid composition of rat liver microsomes.

Letter: Sex difference in normal neutrophil count.

Sex difference in response to varenicline for smoking cessation.

Sex differences in the rapid detection of emotional facial expressions.

Sex ratio influences the motivational salience of facial attractiveness.

Facial feminization surgery: the forehead. Surgical techniques and analysis of results.

[Sex difference in free erythrocyte protoporphyrin (FEP) level. I. Sex difference in FEP level in healthy rural residents].

[Sex difference in free erythrocyte protoporphyrin (FEP) level. II. Sex difference in FEP level in rats exposed to lead].

Sex difference in thermal preference of adult mice does not depend on presence of the gonads.

Sex-related difference in food-anticipatory activity of mice.

Testosterone and the sex difference in blood pressure in mice.

The sex difference in dimensional communalities in Macaca nemestrina.

Sex difference in mortality rates of Leghorn-Red reciprocal crosses.