When the children at Sophia Drakes primary school in rural Wales used to talk about what superpower theyd like, she always told them she wanted to be a shapeshifter. But I didnt want to be an animal. I didnt want to be Spider-Man or Muhammad Ali, I just wanted to change into a woman.

Drake was born biologically male. For as long as she can remember, she felt different and uncomfortable, and experimented with whatever identities and fads she could in an effort to belong. Video games saved her. When she discovered them as a child, she found she could get lost in a world where she could embody any character she liked. They took me to places where I didnt have all those issues and problems; I wasnt this confused child, I could pick who I wanted to be, she told me.

While she was growing up, Drake didnt really know what transgender was, aside from something everyone laughed about in the playground when Nadia was on Big Brother or Chandlers dad was on Friends. Her experiments with makeup and cross-dressing were always secret. When she left home for university, she developed an eating disorder and lost half her body weight in a year. Controlling her food intake fed the fantasy that she could finally shapeshift, after all. It made me feel like I had power, for the first time in my life. In 2016, she married her girlfriend, hoping the discomfort would somehow go away. It never did.

Outwardly I was this confused, shy, reserved young adult. But internally, the person I wanted to be was very different. She found that internal person impossible to suppress. That was natural, that was innate, that was me. This, she splayed her palms across her face that people saw, was the mask. I didnt want to live as a fake person.

After she got divorced, in early 2018, Drake, now working in the games industry, was determined to transition as quickly as she could. She devoured whatever information she could find on Reddit pages such as asktransgender, transgenderuk and transtimelines, and specialist forums for trans women such as Susans Place. The nearest NHS gender identity clinic told her they had a two-year waiting list for an appointment. Some people are on the waiting list for four years, she said. Thats a long time to ask someone to put their life on pause. The point where you get the referral its taken you years, often, to get to that point.

The same year, she found the online, private GenderGP service, and had some consultations via Skype with doctors who prescribed her hormone replacement therapy. She pays about 50 a month for her hormone treatment, and will need to continue with it for the rest of her life.

Drake sought out videos of facial feminisation surgery, in which trans women had their masculine features hairlines, jaws and brows reduced and remodelled. On the Channel 4 programme Embarrassing Bodies, she watched the maxillofacial surgeon Keith Altman transform the face of a transgender patient. Its an expensive procedure, and not available on the NHS in most of the UK, but for some trans women, it can be life-changing.

I first met Drake a year ago, when she was 31, six days before she was to undergo facial feminisation surgery. She was curled up in an armchair at her parents house, a converted barn in St Asaph in north Wales that used to belong to her grandparents. Her hair was pulled back by tortoiseshell sunglasses, and she wore mascara but no other makeup. She was dressed in pink Converse and a patterned shirt dress, and constantly played with her hair, her coffee cup and her ring. Her handheld games console lay on the walnut coffee table.

For Drake, the surgery was about correcting her face so that, when she looked in the mirror, she no longer felt the profound discomfort of gender dysphoria. Im not trying to make a supermodel face, I just want to see the person I always saw in my head, she said.

By and large, facial feminisation is a process of subtraction. For Drake, it is the removal of the changes that testosterone made to her face during puberty. For Keith Altman, the maxillofacial surgeon, it is the removal of bone, skin and cartilage. Facial feminisation is not considered cosmetic surgery. Its goal is to reconstruct the face, not to improve it aesthetically. In his NHS work, Altman could remake your forehead if you smashed it against a dashboard in a car accident. In his private practice, he treats a different kind of trauma: the trauma of not being read as female.

Facial feminisation is a growing industry, with private clinics springing up across the globe over the past decade. It costs twice as much as genital surgery, which used to be considered the standard procedure for gender reassignment, and has been available on the NHS since 1966. People who have undergone facial procedures say they can make an equal, if not greater, difference to a trans persons life, as the face is where gender is first read. Those who can afford it can buy the capacity to pass to go through public life without being identified as trans, without everyone knowing their business.

Drake manages a global competition for independent games developers, a job that involves travelling around the world and speaking on panels to audiences of up to 1,000 people. She is proud of being trans, she told me, and her public-facing job means her transition could never be secret. But it takes her to places where being trans can mean being very exposed.

She said she has faced aggressive transphobic comments, and lots of stares: Sometimes quite disgusting stares. The greatest pain comes when people with no malicious intent misgender her. When you are called to get on a plane and someone calls you sir thats a huge dysphoria trigger. Its like a sickening in your stomach, a pit, a crunching. I find it hard to breathe. To discover that she has not passed is to be reminded that her identity may still exist only in her mind, and not the minds of other people.

Passing means that you probably dont get stared at, pestered, misgendered. Which means you can go through an entire day, maybe, without having a major bout of dysphoria. When youve spent your whole life with dysphoria, thats massive. It means you just get on with your life.

Drake described gender dysphoria as a deep longing to be comfortable. The American Psychological Associations diagnostic and statistical manual (DSM-5) defines it as a difference between your experienced/expressed gender and assigned gender, and significant distress or problems functioning. Untreated gender dysphoria is associated with a higher risk of depression, self-harm and suicidal thoughts.

Some trans people argue that the DSM-5 definition pathologises people when it should not, and that trans is an identity, not an illness. The medical anthropologist Eric Plemons, who specialises in the politics and practice of trans medicine and surgery, told me the current definition of gender dysphoria is an improvement, and that it replaces much more pathologising things that came before it. With gender identity disorder, the identity itself was the disorder. Gender dysphoria is more about moving the problem into the social [arena]. In other words, people are suffering not from their identity, but the stress it causes them in the world. But those codes and diagnoses are currently needed in most cases for trans people to get access to the resources they need, which is unfortunate, Plemons said.

Drake had to take out a bank loan to cover two-thirds of the 14,500 cost of her facial feminisation surgery. But she saw it as vital to her wellbeing, as mental health surgery. She recognised how lucky she was to be able to afford a procedure that she could not get on the NHS. When it comes to the whole inequality in transgender treatment in the UK, I think its just short of criminal, she said.

Drake had no definite idea of how she would look after the surgery. In one sense, I expect to see the person I always wanted to be, to be comfortable, to feel euphoria, a relief from dysphoria. But in the long term, I expect to feel nothing. What does the everyday person think when they look in the mirror and see their face? Its their face.

Under angled hexagonal lights in a Brighton operating theatre in early October 2019, Drake was covered by green surgical draping that exposed only her lower face. As the surgeon, Keith Altman, prised back her cheek with a stainless steel retractor and peered inside her mouth, beams from the three bulbs fixed to his glasses illuminated the furthest interior reaches of her jawbone. From the thick brows above their surgical masks, it was evident that the two surgeons, two anaesthetists and two doctors observing were all men.

Taped to the wall above the nurses station were black-and-white portraits of the patient. In one, she looked directly into the camera with a calm determination in her eyes, bleached-blond hair, an elegant nose, full lips and dimpled cheeks. Another, above it, was shot in profile. Her jaw looked square, and her brow jutted in a prominent ridge. It was Drakes profile that threw into relief the reality that she had been born biologically male.

Altman has operated on the faces of more than 100 trans women in the past 10 years. They have ranged in age from 18 to almost 70, and include a barrister, several academics and three airline pilots. They are generally white, and wealthy enough to afford the typical 20,000-25,000 cost of facial feminisation surgery. Altman is one of only a handful of British surgeons to specialise in it.

The week before Drakes surgery, Altman operated on someone who had a thyroid shave, forehead reduction, brow lift and scalp advance (bringing the hairline forward), jaw angle shave, lip lift, cheek implants and rhinoplasty. She was on the table for seven hours. (By comparison, Drake was having pretty light work done, which was why her surgery was cheaper than average.)

Drake would undergo four procedures that morning. The mandibular angle reduction, to make the jaw narrower and the face more slender, was the first. Altman made a swift incision inside her mouth and pulled back the thin skin covering her lower jaw. A surgical nurse handed him a drill with a stainless steel bit. Music on, he declared, and soon the sound of There She Goes by the Las was wafting through the room, above the gentle whirr of Altmans drill.

When the job was done, Altman flicked his green surgical glove into a bin and left the theatre for a coffee break while the anaesthetist moved the breathing tube from Drakes nose to her mouth. Next, her brow bone would be shaved, a section of her forehead would be filed, and her hairline would be moved down. The whole procedure would take two-and-a-half hours.

When a trans woman called Candice had breast implants and genital surgery in California in 1982, she returned to her surgeon, Darrell Pratt, a few months later to say that it had had no impact on how other people perceived her in everyday life, because her face looked masculine. Pratt asked a colleague, the San Francisco-based maxillofacial surgeon Douglas Ousterhout, if there was anything he could do for his patient.

Ousterhout busied himself in the study of early-20th-century physical anthropology. He examined 1,500 male and female skulls in search of a clinical, craniofacial basis for the maleness people were apparently seeing in Candices face. He noted differences in jaws, upper lips, foreheads and chins. (Male chins are 17% longer than female chins, according to his calculations.) He considered mathematical takes on beauty, the golden ratio of pleasing proportions first theorised in ancient Greece. The formula for femininity he came up with has formed the basis for facial work ever since.

While there is no doubt that testosterone does change skulls in puberty, how much is up for discussion. Mathematical formulas for beauty have fallen out of fashion, and surgeons have different opinions about what kind of work can be done to a skull to make a face look feminine. There are no standard clinical protocols, and the 120 pages of guidelines published by the World Professional Association for Transgender Health contains a single line on FFS. It says only that there are no criteria for standards of care for facial surgery, but that mental health professionals can play an important role in helping their clients to make fully informed decisions about the timing and implications of such procedures.

Sophia Drake spent six years playing in secret with apps that make faces look more masculine or feminine, creating folders full of gender-transformed selfies and hiding them on her computer. There are sites, such as virtualffs.co.uk, that are specifically aimed at trans women, and will, for a fee, apply Ousterhout-like principles to photos. Im not trying to make myself beautiful, Drake said. I see testosterone as a poison in my body, a poison that I had to deal with for 20 years. I want to put my face to the way it would have been if testosterone had never been pumping through my body. And thats it.

Altman talked me through his working principles over coffee before Drakes surgery. Youre not doing this to beautify or rejuvenate, youre doing it to feminise, he said. If you have an attractive male face, youll end up with an attractive female face. I asked what he meant by attractive symmetrical? and he replied without missing a beat. No. I mean pleasing. What we feel is attractive. Of course, its subjective.

A female face has rounder edges and fewer angles, Altman explained. You have a more obtuse angle between your forehead and your nose here, he said, smoothing a finger between the middle of his brows. High cheekbones, a curved jawline, pointed chin. Lack of an Adams apple. Nice skin. No hair on the face, generally. And then theres the female hairline, a low hairline. The focus of his work was to bring attention to the eyes. If you file off the forehead, it looks as though the eyes have come forward, and raising the brow opens up the eyes.

Altman came to this field relatively late in his career, which has largely been spent in the NHS, remaking the faces of people who have been in car accidents, or breaking and remaking peoples jaws in orthodontic surgery. Ten years ago, a London-based GP began referring trans women to him. He contacted a surgeon in Antwerp who was experienced in facial feminisation surgery, and who invited Altman over to watch him at work. After two visits to Belgium, he began operating on his own patients in the UK.

The greatest accolade his patients can give him is to tell him that no one calls them sir any more. Thats what I want to hear. Not Im beautiful. They dont stick out. They blend in. They dont want to be going, Im a woman!, flying a flag. They can quietly go about their business, without risk of violence.

Altman was gearing up to hand his practice over to his trainee, Nikhil Maini. Demand remains steady. Many of his patients travel from Northern Ireland, where the procedure is covered by the NHS. But the lack of provision in the rest of the country leaves desperate people open to exploitation. He has heard of several trans women who have had consultations with so-called fly-in-fly-out doctors: surgeons from overseas who might not have a licence to practise in the UK, but see prospective patients in hotel rooms and offer cut-price surgery abroad.

He was confident about Drakes forthcoming surgery. She looks pretty good anyway. Shes got a nice nose. She could get away without having this done, he rubbed his jawbone but the forehead, she does need. Youll see the difference there and then on the table. I cant remember anyone whos been really upset with the outcome, he added. And certainly no one has ever said they want to be a man again.

On 28 October 2013, a thread appeared on the Susans Place message board titled Ive stopped HRT today. It had been posted by Joanna Holford, a trans woman who had had facial feminisation surgery with Altman the year before. Holford has been documenting her transition on her YouTube channel since 2012.

I pass as female but often with a second glance or prolonged look, her post read. Im tired of the stress and constant insecurity and I am not sure I can take it any more. She had written two lists, for and against detransitioning. The against column included the line: Giving up on my dream of being a fun and vivacious woman.

She decided against, in the end. She now recognises the post as a low point, triggered by the loneliness of being single for the first time in a decade and moving to a new city, and the suspicion that, despite having had facial surgery, she still wasnt always read as female.

After the surgery, Holford had moved to London to be by herself, just completely anonymous, and go stealth I hate that term, but thats what they call it, she told me. She was finding her feet enjoying life, even when a series of small incidents rattled her. She noticed people staring at her on the tube. A female colleague who had always been friendly came into work one day and blanked her. Then there was a man who looked Holford up and down in the staff canteen, then turned away, only to look back and stare again. And the time she overheard a man from another department asking the woman at the desk next to Holford whether Holford was a man or a woman, and whether she felt uncomfortable sitting so close to her.

I just died. I couldnt work out what Id done wrong. I suddenly rechecked myself. Is there something wrong with my hormones? Am I sitting in the wrong way? Is the lighting really bad? Is my clothing really bad?

Even after more surgery, and even though her videos are shared on message boards as an example of a transition to be envied, Holford still finds passing a daily effort, a daily chore. The gender dysphoria she felt before her transition has transmuted into a real, chronic paranoia. FFS isnt the golden ticket to passing. It definitely helps. If youre able to afford to do it, Id always say its a good idea. But there are so many other elements to passing: the way you handle yourself, the way you speak, the clothes that you choose, the belief you have in yourself.

Holford accepts that facial feminisation surgery perpetuates the idea that there is such a thing as a normal female face, that there is a standard expectation of what a woman should look like, and that any woman who falls outside of that is less feminine. She said the pressures women are under to look a certain way were unfair. Not just for trans women, but for women in general. There are women with heavy brows and square jaws but they still look absolutely beautiful in their own way. It puts completely unfair pressure on cisgendered women I think its awful but for trans women its double, and youd do anything just to feel like you fit in. Just to feel you can get on with your life. Because you dont want to keep fighting all the time. If this is going to help, why wouldnt you do it?

Some trans people object to facial feminisation surgery on the grounds that it reinforces a culture that cant accept trans people, instead of challenging it. Many trans women choose not to alter their bodies with surgery. In 2015, while Caitlyn Jenners feminised face was on the cover of Vanity Fair, the actor Laverne Cox began using the #TransIsBeautiful hashtag, starting a movement for trans people to be accepted without surgical intervention. Juno Roche, author of Trans Power, argues that being recognisably trans means refusing to allow gender norms to control you. The history of the trans journey is a cis male, hetrosexual, often white, middle-aged, middle-class doctor saying hes going to make you look as close in proximity to a woman so that you can pass without being noticed, so you can blend into the background, Roche told me.

Facial feminisation has allowed for the creation of a kind of two-tier system where, on the whole, the most successful trans people are beautiful people that pass, Roche continued. People who are proud to be trans, and those people who cant afford the surgery, fall into a separate category. Thats most people. And we have to create safety for everyone. It impacts on so many people, not just trans people.

Roche understands the appeal of facial surgery for so many trans women. If somebody wants to have an easy life, then boy, trans people deserve an easy life. This is a tough gig. But the truth is, if testosterone has shaped your face, it will have shaped your shoulders, your shoulder-to-hip ratio. It will have shaped your hands. Where does it stop?

There was no more easy chatter between the doctors when Altman returned to the theatre to operate on Drakes brow and forehead. This was the most difficult part of the surgery. It would remove the parts of Drakes face she thought were most male, the features she hated so much. Altman brushed sterile aqueous iodine over her face and hair, rendering her first rusty red and then yellow. He made an incision into her hairline with a swift, steady hand.

He drew back her skin in either direction from her hairline until it gathered in folds on one side at the tip of her nose, and draped back across her crown on the other. With a tiny steel mallet and a chisel, Altman set to work carefully chipping away her brow bone, before filing it with a tiny drill bit. Then he stopped, and everyone in theatre craned in to see the difference.

When he was satisfied with the result, Altman changed his gloves and turned his attention to her forehead. The MRI on the lightbox showed Drake had a large sinus cavity with a thin wall; the challenge was to saw the bone down without perforating the sinus, and the best way to do this was to remove part of her forehead entirely. Altman drew a 5cm by 3cm rectangle on to her skull with marker pen. He sliced into it with another fine tool, then prised out the section of bone. He held it in his hand as he filed it back, turning a flat plane into a gentle curve. When he put it back in place, he pulled the skin over it, tilting his head to the side to check his work. Finally, the piece of forehead was fixed back in the skull with two 4mm titanium plates, which his trainee, Maini, secured using a tiny screwdriver. Drakes skin was smoothed back for a last time. Good, Altman nodded.

The final procedures were on Drakes brow and hairline. First, the brow was lifted and anchored by two stitches. Then Altman drew in a new hairline, a centimetre below Drakes natural one, and sliced out the excess strip of skin. He fixed the hairline in place with a ladder of surgical staples at her temples and blue stitching along the top of her forehead, with a practised tilt of his wrist. Altman was right I could see the difference there and then on the operating table. Drake protruding brow bone, which she had struck with the side of her index finger when she told me about the poison of testosterone, was gone.

Altman gently rinsed the blood from Drakes hair, and wrapped her head in a tight bandage before she was wheeled out of theatre. That went well, he said, as he pulled the black-and-white portraits of Drakes old face down from the theatre wall.

The moment Drake opened her eyes in recovery, she asked the nurse beside her to take her picture, but she fell back asleep immediately. By the time she was properly awake and back in her hospital room, the Face ID on her iPhone no longer worked because her face was so swollen.

Drake had been warned that recovery could be difficult. For the first couple of days, whenever she got out of bed, she would vomit the blood that had collected in her stomach from the surgery inside her mouth. When she finally felt ready to eat, using her jaw was agony; she lived on soups, sorbets and mushed-up jelly. Drains collected the fluid that was accumulating under her skin.

But, two months later, Drake was delighted with the results. I met her in a busy cafe near Euston station when she was in London for work. The change was almost imperceptible to me, at first. But I could soon detect a new poise: her face seemed narrower, and strangely her shoulders did, too. Her dimples were more prominent, her eyes looked brighter and more expressive. There was a faint, pale pink sliver of a scar along her hairline, mostly covered by the dark roots of her fringe.

It was just enough, without being too much, she told me. The hairline frames my face better. I find that my eyes arent sunken, theyre further out. I feel that Ive got a lot more expression in my eyebrows now. Other people spot this she cupped her hands around her jaw more than I do. But when I go back and look at old pictures, I see a massive difference.

The biggest change was in Drakes demeanour. She no longer sat with her arms across her chest or played with her jewellery. She was open, at ease, comfortable.

Its made me so much happier. Calmer. I can sit and relax in ways Im not sure Ive ever been able to, she said. I dont walk around any more worrying that people are looking at me, and looking at my brow bone.

She once feared wearing too much makeup would draw attention to her brow, but now accentuated her eyes with flicked eyeliner. Where she once might have been met with stares, she told me she now gets nothing. For the first time, shes confident enough to go shopping and try on clothes in womens changing rooms as long as there are private cubicles. Before, there was a constant feeling of not wanting to make other people uncomfortable, a self-censorship. Now, I dont need to worry.

The sole NHS youth gender clinic in England and Wales has experienced an average 40% annual increase in referrals over the past four years, with many of their child patients asking for puberty blockers so their bodies will not go through the kinds of changes Drake has spent thousands of pounds trying to address. Perhaps, in the future, the availability and acceptance of hormone treatment will mean there will be fewer people requiring or wanting facial procedures. Drake thinks there may always be a need for it, because there will always be people like her who understand who they are later in life.

Facial surgery was only one step in a long journey for Drake. Things will tighten up, obviously the scar will slowly reduce over time. We wont see the full effects until next year, she said. But the authentic Sophia Drake she is looking for in the mirror is still several procedures away. On my face, Im 75% there. I still have things I want to do on my body. She nodded. Im planning other surgeries.

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'I just want to see the person I always saw in my head': the story of a face - The Guardian

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