Chick's in the Male

Under a proposal receiving serious consideration by the city, health insurers may be required to cover the cost of municipal workers' sex changes

The most surprising thing about Roberta Dunne's sex change isn't that she had one. It's that her insurance paid for it.

"My operation cost over $50,000, and I didn't have to pay a penny," says Dunne, 51, a Sunset resident who underwent male-to-female sexual reassignment surgery in November 1994. "I paid into the system for all those years, so I think it's only fair."

In an age where it can take months to get reimbursed for a routine visit to the doctor, it's hard to imagine an insurance company paying for someone's decision to make himself different from the ground up. But Dunne's experience may soon become more commonplace. San Francisco is currently considering a proposal that would require health insurance carriers to pay for city workers' sex-change operations.

"To me, it's the right thing to do," says Supervisor Tom Ammiano, who is actively supporting the proposal. "Transsexuals are real people with real needs. The fact that their medical condition isn't covered in the city health plan is based on institutional prejudice."

While the rest of the country is still arguing over gays in the military and same-sex marriages, S.F. has moved on to brave new gender frontiers. San Francisco has a long history of accepting gender-benders as part of the natural order, a sense of tolerance that stretches back to before Europeans even settled the area. In the late 1700s Father Francisco Palou, a Franciscan missionary in Northern California, wrote to his superior about a peculiar custom of the native Ohlone Indian tribe that caught his attention:

"There was one [native] who by the dress ... had all the appearances of a woman, but judging by the face and absence of breasts, though old enough for that, they concluded that he must be a man, so they asked some of the converts. They said it was a man, but that he passed himself off always for a woman and always went with them and not the men."

Continuing the tradition 200 years later, the city's Human Rights Commission is following on earlier anti-discrimination measures protecting transgenders by pushing to make S.F. the first American city to cover city workers who want to have a sex change. As it stands now, city health plans don't cover sex-change operations or related hormone treatments, placing them in the same excluded category as elective surgeries such as breast enhancement and procedures considered to be "experimental" such as radial keratotomy to correct nearsightedness.

But transsexuals, and some doctors who work with them, say that gender reassignment should be treated as an often necessary and cost-effective medical procedure, not as a mere lifestyle choice. In fact, the Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatric maladies, lists the condition as "Gender Identity Disorder," and assigns it Code 302.85. The condition is marked by "evidence of a strong and persistent cross-gender identification, which is the desire to be, or the insistence that one is of the other sex."

"For some people, [sex-change] surgery is a legitimate treatment for a medical condition," says Dr. Barry Zevin, medical director for the city's Tom Waddell Clinic. "It probably saves money in the long run to treat it properly rather than ignore it and have it involve suicide or long-term mental health services."

Not everyone in the city is enamored of the proposal. Callers to local radio talk shows have been sharply critical, some vowing to fight rather than pay for someone else's switch. Supervisor Ammiano reports that someone left a message with his office saying, "We'll pay for a bullet, but not an operation." Others have raised the ugly specter of the city's municipal rolls swelling with legions of preop "welfare queens."

"Do we want people to come from all over the world to join our bloated bureaucracy and get $30,000 sex-change operations as well?" sputters Arthur Bruzzone, chairman of the city Republican Party. "This is not a medical condition -- it's cosmetic surgery."

Even some medical experts believe that sex-change operations are a misguided medical response to an unresolved psychological problem, a cosmetic fix to an internal conflict.

"There's nothing cosmetic about this change," retorts San Francisco police Sgt. Stephan (formerly Stephanie) Thorne, 42, who is undergoing the change from female to male at his own expense. "It's not a nose job."

Thorne, a 12-year veteran of the SFPD, decided to start the sex-change process three years ago, but discovered that the fine print of his HMO plan excluded "medical or surgical care for sex transformation." Thorne took out a loan to pay for a series of operations and biweekly hormone treatments, and has spent about $10,000 so far. Gender reassignment, often a series of surgical procedures, costs from $10,000 to $50,000 and more, depending on the complexity of the operation. (Female-to-male sex changes are usually more expensive because, as surgeons in the field are fond of saying, "It's harder to make a pole than a hole.") Psychiatric evaluations -- required before surgery can be performed -- and lifelong hormone treatments ($80 for six months of testosterone; $15 if you go generic) add to the cost.

For Roberta Dunne, a lifelong struggle with gender identity has had incalculable costs.

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