Throughout his career, Spiegel has performed over 1,000 cases of FFS, and he’s not the only one who has taken on this specialty. In the past decade, FFS has become an industry of its own, with surgeons performing the procedure in many states and around the world. The number of clinics performing FFS is rapidly increasing every year, to the degree that most new patients must spend time on a waiting list.

But with its tremendous growth has come intense debate, particularly among members of the trans community whose beliefs about passing are varied and fraught. Conflicting ideas about FFS have also entered mainstream culture. In June 2015, it was revealed that trans celebrity Caitlyn Jenner underwent ten hours of FFS. Shortly after, trans actress Laverne Cox shared her own views on FFS, saying, “Years ago, I wanted really highly invasive surgical procedures to feminize my face. All these years later, I have the money to do it, but I don’t want it.”

Cox began the #TransIsBeautiful movement dedicated to embracing trans beauty in all of its glory. “All the things that make me uniquely and beautifully trans — my big hands, my big feet, my wide shoulders, my deep voice — all of these things are beautiful,” Cox said. “I’m not beautiful despite these things, I’m beautiful because of them.”

The complicated reality is that while FFS can provide trans women with remarkable relief, it also can produce the notion that there are essential differences between male and female faces. After all, when grouping together a specific set of cosmetic alterations as a means of “feminizing” certain features, there is, invariably, a troubling message that is communicated: that looking like a woman is uniform and that cisgender beauty standards are the norm from which transgender bodies deviate. For some trans people, this message reinforces restrictive stereotypes that ultimately fuel the same violence and discrimination that FFS is advertised as protecting trans women from.

Serving “realness,” as they say in the trans community, is often said to be the ultimate goal of transitioning, but in hindsight, I was real all along, regardless of what anyone thought about me.

And with the price tag of FFS often in the tens of thousands of dollars, there’s certainly an uncomfortable feeling that comes with contributing to an industry that profits from our pain. For the vast majority of trans women, FFS is not an attainable reality; in performing FFS procedures, surgeons are upholding an idealized notion of feminine beauty, but making it accessible only to a few.

That said, for many trans women who do undergo FFS, it is not for the purpose of conforming to cisgender female beauty ideals, but as a means of alleviating feelings of gender dysphoria. Gender dysphoria, as defined by the American Psychiatric Association, describes “a conflict between a person's physical or assigned gender and the gender with which he/she/they identify.” It is also important to note that for trans people, our feelings of gender dysphoria are not necessarily inherent to being trans. They are, at least partially, a side effect of living in a society that constantly tells us that being visibly trans is unacceptable.