This chapter engages the ethical history of American trans- medicine as a distinct “geography of care” and shows how that history continues to bear on the clinical present. Surgeons’ efforts to frame their work with trans- patients in ethical and affective terms both respond to the fact of poor trans- health care and leverage that legacy to distinguish “good” surgeons from “bad.” Described as an act of friendship, generosity, and deific repair that patients reciprocate with gratitude, loyalty, and individualized moralistic praise, facial feminization surgery is an act of restitutive intimacy whose status as such depends on the elision of the financial transaction between doctor and patient. Establishing themselves as caring for trans- patients for “all the right reasons,” surgeons depend in part on the cultivation of affect as a vital surgical technique to be able to surgically enact “woman.”