Social Perception of Facial Feminization Surgery Outcomes: Does Gender Identity Alter Gaze?

BACKGROUND: The evaluation of gender-affirming facial feminization surgery (FFS) outcomes can be highly subjective, which has resulted in a limited understanding of the social perception of favorable gender and aesthetic facial appearance following FFS. Eye-tracking technology has introduced an objective measure of viewer subconscious gaze. OBJECTIVES: The aim of this study was to use eye-tracking technology to measure attention and perception of surgery-naive cisgender female and feminized transgender faces, based on viewer gender identity. METHODS: Thirty-two participants (18 cisgender and 14 transgender) were enrolled and shown 5 photographs each of surgery-naive cisgender female and feminized transgender faces. Gaze was captured with a Tobii Pro X2-60 eye-tracking device (Tobii, Stockholm, Sweden) and participants rated the gender and aesthetic appearance of each face on Likert-type scales. RESULTS: Total image gaze fixation time did not differ by participant gender identity (6.00 vs 6.04 seconds, P = 0.889); however, transgender participants spent more time evaluating the forehead/brow, buccal/mandibular regions, and chin (P < 0.001). Multivariate regression analysis showed significant associations between viewer gender identity, age, race, and education, and the time spent evaluating gender salient facial features. Feminized faces were rated as more masculine with poorer aesthetic appearance than surgery-naive cisgender female faces; however, there was no significant difference in the distribution of gender appearance ratings assigned to each photograph by cisgender and transgender participants. CONCLUSIONS: These results demonstrate that gender identity influences subconscious attention and gaze on female faces. Nevertheless, differences in gaze distribution did not correspond to subjective rated gender appearance for either surgery-naive cisgender female or feminized transgender faces, further illustrating the complexity of evaluating social perception of favorable FFS outcomes.