In second grade, back in 1953, Tami Goodhue remembers sneaking to a corner of the St. Mary’s School playground in Melrose, where she'd make herself throw up. "I battled bulimia, anorexia," says Goodhue, now 71, describing her symptoms of self-hatred. "Every time I looked in the mirror at myself, I didn’t see me. I saw something else and it made me sick." Sick because what she saw then was a boy named Jimmy. By ninth grade, Goodhue was drinking to numb depression and a sense of living in the wrong body. While still presenting to the world as “he,” Goodhue joined the Navy and then the Melrose police force, praying these jobs would help her look and feel more like a man. "If we had to kick down a door I’d be the first one through the door, because that’s what I was supposed to do to, uh, prove that I was something that I wasn’t," Goodhue says. The nearly 6 foot, lean, hyper-macho Goodhue cracked many times under the weight of pretending. Breakdowns led to seven psych ward commitments and two attempts at suicide. Then, in her early 50s, Tami stopped trying to live as male. She bought a purple miniskirt and red lipstick. Amid the relief and emerging self-confidence, Goodhue got a divorce. Three of her six brothers and sisters stopped talking to her. But she found acceptance too: from her daughter, from buddies in the Melrose PD, and at her daily haunt, the Mount Hood Golf Club. Goodhue has spent almost 20 years and thousands of dollars trying to match the way she looks with the way she feels inside. She's on cross-sex hormone therapy, has lasered smooth cheeks, is fond of gauzy blouses, and flashes bright red nails. Still, when she steps into a restaurant and asks for table, Goodhue often hears, "'right this way, sir' and it’s, it’s devastating." So Goodhue is preparing for what she says could be the most important step in her physical transition: facial feminization surgery (FFS). It's a step that places her in the middle of a controversy about what it means to make a medical gender transition, and raises a broader question: Just what makes someone appear female? What Is Facial Feminization Surgery? Goodhue sits on a black salon-style chair in an exam room at Boston Medical Center. The man she's chosen to transform her face is on a rolling stool to her right. "Let's talk about your goals and how to achieve them," says Dr. Jeffrey Spiegel, a plastic surgeon in the hospital's Center for Transgender Medicine and Surgery. "To help me pass as the woman that I am," Goodhue responds. "It’s my dream." Surgeon Dr. Jeffrey Spiegel demonstrates to Goodhue where along her jaw line the feminine facial surgery would occur. (Jesse Costa/WBUR) "OK, let me show you what we do," says Spiegel as he glides toward Goodhue and extends a hand, fingers splayed, just above her protruding eyebrows. "This sort of ridge here, that comes out," Spiegel tells Goodhue. "This is probably the most significant part of how we judge a person as male or female, when looking at their face. What we do is we set that back." Spiegel explains three more parts of the surgery he envisions for Goodhue: a smaller nose, a more heart-shaped jaw and a less prominent Adam’s apple. These are common elements in an evolving practice that is growing with demand. The number of clinics in the United States that offer FFS is increasing every year, and most patients wait weeks if not months for an initial appointment. The Face Matters Demand for facial feminization may be a byproduct of increasing recognition and more Americans coming out as transgender. But there's another theory: It's that the face matters as much, if not more, than the genitals or chest. The face determines whether someone is seen as male or female, says Eric Plemons, author of "The Look of a Woman: Facial Feminization Surgery and the Aims of Trans-Medicine." "The trans women would say over and over again, 'Yes, maybe one day I'd like to have genital surgery, but what will change my life today is the way I look on the street,' " Plemons says. For decades, a full gender transition has been defined by genital reassignment surgery. That's beginning to shift as doctors ask patients what they want. A study of 99 transgender patients at Boston Medical Center found that most only received hormone therapy and had not sought surgery. Among the 28 percent of trans women who had pursued surgery, Dr. Joshua Safer, a study author, says they were equally interested in genital and facial surgery. Cost may have been a factor. The data was collected before Massachusetts began, in 2015, requiring that health insurers cover gender transition services. Costs aside, Safer says it's time to rethink the expected path for transgender patients. Until recently, the general thinking was that patients "started with mental health, moved on to hormones and then to genital surgery," says Safer, an endocrinologist who directs BMC's transgender medicine program. Safer's own patients show "we had that wrong to be so genital-focused."

"The trans women would say over and over again, 'Yes, maybe one day I'd like to have genital surgery, but what will change my life today is the way I look on the street.' " Eric Plemons

Safer says patient interest in FFS may wane as more transgender females begin their transitions early in life, before puberty. Trans girls who go into puberty on cross-sex hormones avoid many of the more masculine facial features. And there's a growing population of transgender individuals who don't identify as male or female and never pursue any kind of medical transition. Those who do seek facial changes are almost always trans women. Safer says trans men are typically satisfied with the masculinizing effects of testosterone, such as facial hair. But for trans women, Safer says "facial feminization surgery may be the most important surgery they require and be their highest priority." How FFS Came To Be, And Beauty Metrics What’s become facial feminization surgery today began in 1982, when a colleague in San Francisco referred a transgender patient to Dr. Douglas Ousterhout, a craniofacial surgeon. The colleague asked Ousterhout to feminize the trans woman's forehead. "I said 'OK' and then I realized I had never thought about the difference between boys' and girls' skulls, period. Not even a tiny bit," Ousterhout says. So he pored through books on physical anthropology and headed for a local dental school library. Ousterhout says he examined 1,400 to 1,500 male and female skulls and found some consistent differences. The vertical height of the male chins he measured, for example, was 17 percent higher than the typical female chin. Ousterhout developed a series of similar calculations for the forehead, nose, upper lip and jaw. He devised surgical procedures, including four to recess and reduce the forehead. He also considered mathematical theories about beauty. To create a beautiful face, says Ousterhout, you have to get the proportions right. And right to him means using the golden ratio, or golden mean, creating a 1 to 1.6 relationship between the base of the nose and the forehead, and then between the base of the nose and the bottom of the chin. "If you see someone who in your mind is really attractive, I will bet they fit into the golden mean," Ousterhout says. Before shifting to semi-retirement, Ousterhout transformed more than 2,000 transgender women, one living skull at a time. "You would modify it and it was fantastic, what it did," he says. "You never saw such happy patients in your life, I mean they look female." Ousterhout's theories are practiced by some surgeons who perform FFS today, but there's a growing, distinctly different approach, says author Plemons, who's also an associate professor of anthropology at the University of Arizona. In the newer approach, patients are more involved in deciding which parts of their face they want to change and how. The goal is not necessarily beauty, says Plemons; it's to help a trans woman look their best. "That best self doesn't necessarily have to fit a metric," Plemons says. Other doctors say beauty metrics are outdated. "The truth of the matter is that what allows a face to look feminine is somewhat unknown, but not entirely," says BMC's Dr. Spiegel. He lectures on the importance of lifting the brow ridge to brighten a trans woman's eyes and giving patients an overall more youthful look. "It's somewhat clear that as women get older, their faces start to look more masculine," Spiegel says. "Some of this relates to the biology of reproduction. Everything comes back to that somehow." There's another big unknown in research on facial feminization: How will techniques vary for black, Asian and Latina trans women? Plemons says most of the medical literature uses Caucasian norms. The vast majority of trans women who have FFS are white and able to pay cash. That would likely change if more insurers covered FFS. What's Covered And What's Not Insurer coverage of transgender medicine is growing, but many policies limit or exclude facial feminization. Medicaid does pay for it in Massachusetts and the vast majority of states. Medicare doesn't ban reimbursement for FFS, but doesn't guarantee it either, so doctors say coverage is spotty. "The gray area of transgender surgical coverage is with facial feminization," BMC's Safer says. "[Insurers] think about facial feminization as a cosmetic procedure because that's what it would be for the general population, and cosmetic procedures are not typically covered." Insurance policies that do include facial procedures for trans women tend to cover bone reconstruction and label it medically necessary. Non-trans women, who may also be distressed about their masculine-looking faces, still pay cash. "Mandating that you be transgender [to have the surgery covered] runs the risk of a discrimination issue in a different direction," Safer says, "so that’s exactly where the most fraught conversations are occurring right now." FFS is expensive, in the range of $30,000 to $50,000, depending on what the surgery includes. There's another reason insurance coverage is not uniform: There are no medical protocols for FFS. A group of physicians and researchers, including Plemons, is urging the World Professional Association for Transgender Health (WPATH) to adopt a set of six medically necessary procedures: forehead reconstruction (including eyebrow re-positioning), lower jaw and chin contouring, nose reshaping, shaving the Adam's apple, hairline treatment or redefinition, and laser hair removal or electrolysis. But Jamison Green, WPATH's immediate past president, says he's not sure that calling these six steps medically necessary and leaving other facial changes off the list makes sense. "I think a physician ought to be able to look at each individual person and do what's best for them," Green says. "These are the most common procedures, but trans people all have different characteristics." Tami Goodhue's insurer, Harvard Pilgrim Health Care (HPHC), is "one of the best for helping transgender patients," Spiegel says. It covers the four FFS procedures Goodhue discussed with Spiegel but not enhanced lips, a chin lift or cheek implants that Goodhue says she needs. "To say it’s cosmetic, no, it’s just something that I need so badly," Goodhue says. "I want to be who I am." When asked why coverage is limited to the forehead, jaw, nose and Adam's apple, HPHC sent this statement: Harvard Pilgrim was one of the first health plans to cover transgender surgeries, including facial feminization. Our policy covers the most essential elements of the feminization process, and we are currently re-evaluating it for expansion. Our goal is to ensure that it meets the needs of the transgender population and our ongoing commitment to health equity. 'We're Making History Today' Goodhue hopes to have the facial surgery next year. It would cap a series of changes. In March, on International Women’s Day, Goodhue had surgery to reconstruct her genitals. She's having some complications, but says she has no regrets. She's filed for a new birth certificate that would change the one issued by Melrose Hospital in 1946 from "boy" to "girl." And this past summer, Melrose Mayor Rob Dolan and a group of dignitaries gathered at City Hall to honor Sergeant Goodhue with a new ID. "We’re making history today, in a lot of ways," Dolan told a crowd of Goodhue's friends, family and colleagues. "In gratitude for all you have done for our community. We offer you this police badge, Tami M. Goodhue, retired Melrose police officer."

"I'm so glad my dad can finally be recognized as the person she's comfortable being." Nicole Goodhue