Background: Critical Race Theory (CRT) within legal scholarship explores the ways in which race and power systems are constructed and enforced within the law and society more broadly (1,2). CRT extended as a conceptual framework within medicine elucidates health disparities and barriers to care (3). Similarly, feminist theory explores the role of gender and sex. Feminist and gender theory have been helpful frameworks for understanding gender diverse lived experiences, including Butler’s theory of performative gender which describes gender as acts influenced by societal norms (4) CRT and feminist theory can offer new insights into how plastic surgeons can navigate the complexities of identity, race and gender while acknowledging the reproduction of these social constructs.

Methods: A query of literature across disciplines of law, medicine, and social sciences was conducted via searches in JSTOR, Westlaw, Lexis and PubMed. Search terms included “facial feminization”, “gender”, “facial features”, “craniology”, “critical race theory”, “plastic surgery”, and “feminist theory”. This work represents analyses completed under the academic standards set by UCLA Law Substantial Analytical Writing (SAW) requirements.

Results: 28 books and articles were included. The description of gender and facial features were discussed in 16 (57%), the history and practice of FFS in 13 (46%) and theory in 12 (42%). This literature demonstrated that both CRT and feminist theorists have argued that the construction of race and gender are the result of social processes that link symbolic social meanings to physical attributes. This literature also described the pioneering of facial feminization surgery (FFS) as well as the skull data utilized for identifying the surgical plan for FFS. This literature further discussed the shifting views of the medicalization of transgender care.

Conclusions:  Theories of both race and gender can offer insights for gender diverse patient care. The intersectionality of race and gender is particularly salient when considering the care of transgender patients, particularly gender diverse people of color. Feminist and CRT can be considered by the plastic surgeon providing facial reconstruction in the following ways: (1) Some socially constructed markers of race are the same physical features that are altered in FFS and, therefore, could alter how one is viewed racially. (2) We cannot escape the social fabrications of how we perceive race, but we can bring awareness to these racial archetypes and not rein scribe them as biological but understand them as socially constructed referent. (3) Aesthetic FFS choices may rein scribe both racial and gender markers that hew to a socially constructed feminine or non-binary ideal. The field should consider how FFS may be attuned to a broader spectrum of possibilities for what “feminine” or “non-binary” might look like to allow for greater within-race and across-race variation.

References:

1.             Crenshaw K. Demarginalizing the Intersection of Race and Sex. Univ Chic Leg Forum. 1989;1989(1):139-167.

2.             Haney-López I. The Social Construction of Race: Some Observations on Illusion, Fabrication, and Choice. Harv Civ Rights-Civ Lib Law Rev. 1994;29:1.

3.             Tsai J, Lindo E, Bridges K. Seeing the Window, Finding the Spider: Applying Critical Race Theory to Medical Education to Make Up Where Biomedical Models and Social Determinants of Health Curricula Fall Short. Front Public Health. 2021;9:653643.

4.             Butler J. Gender Trouble: Feminism and the Subversion of Identity. 1990.

Acknowledgements:

​Emmanuel Mauleón

Bernard A. and Lenore S. Greenberg Teaching Fellow, UCLA School of Law