Background: Transgender medicine and research has predominantly focused on patients who identify as trans male or trans female, thereby omitting the increasingly recognized “nonbinary” gender identity. Studies have shown that individuals who identify as nonbinary have lower rates of gender-affirming interventions, and as a result, the preferences of facial appearance in this population have not yet been described. We seek to elucidate nonbinary patient preferences regarding the appearance of certain facial features typically involved in gender-confirming facial surgery (GCFS), including the forehead, brows, nose, orbits, cheeks, and chin. We hypothesize nonbinary patients will demonstrate satisfaction with a broad range of facial appearances, with a tendency towards more gender-neutral features, while transgender individuals will prefer more feminine or masculine features depending on their gender identity.

Methods: These preferences were assessed by using a crowdsourced, one-time, voluntary survey of self-identifying nonbinary and transgender individuals using Amazon Mechanical Turk. The questionnaire collected participant demographic data, history of prior medical or surgical interventions, and preferences of facial features, specifically of the frontal and lateral forehead and frontal and lateral mandible, selected on a Likert scale. This data was statistically analyzed using ANOVA single-factor and two-tailed t-Tests on Microsoft Excel. 

Results: Over June and July of 2021, we received 4.8K responses from Amazon Mechanical Turk Workers who were 18 years of age or older, lived in the United States, and had a minimum 95 percent approval rating on Amazon Mechanical Turk. Participants did not receive compensation for completing the survey and were prevented from completing the survey more than once. Responses were narrowed down to eighty-seven (87) based on transgender and nonbinary gender identity. The average age of responders was 32 years old and 77% were of White ethnicity. There were no significant differences noted between trans male and trans female preferences in any of the facial features. There was a clear trend in mandible preferences with trans females favoring more female-appearing mandibles (thinner and less squared) and gender nonbinary individuals favoring more neutral and female-appearing mandibles. The majority of nonbinary (51%) and transgender individuals (64%) would consider an electronic tool to upload photos and simulate facial appearance after GCFS to be very or extremely useful.

Conclusion: We hypothesized that gender nonbinary individuals would favor more gender-neutral appearing facial features. There is no significant difference in any of the categories for what transgender males versus transgender females preferred in this survey. Responses are overall more clustered towards gender-neutral features. There was a significant difference between lateral mandible preferences in transgender males versus gender nonbinary individuals (p=0.050), showing nonbinary individuals preferring more neutral and female-appearing mandibles. Moving forward, we would like to assess individuals’ satisfaction with their facial appearance as part of this survey to determine whether nonbinary patients inherently experience less dissatisfaction with their appearance. With this ongoing project, we aim to establish a patient-centered individualized approach based on simulation in the pre-operative phase of GCFS. Ultimately, our goal is to achieve a reduction of gender dysphoria and optimal patient satisfaction.

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