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This chapter explores the origins of facial feminization surgery in San Francisco in the early 1980s, focusing on the pioneering surgeon Douglas Ousterhout. Analyzing how his treatment philosophy has changed over time, the chapter shows how shifts in ideas about sex and gender and in the delivery of trans- medicine in the dynamic 1990s impacted the way he understood and performed FFS. Initially committed to the genital-centric definition of transsexualism, in relation to which FFS was complementary, over time and in consultation with his patients Ousterhout came to understand FFS as itself enacting a change of sex.

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