COSTLY TRANS-ACTION.

WITH REASSIGNMENT SURGERY EXPENSES AS HIGH AS $50,000 SOME TRANSSEXUALS MUST DECIDE BETWEEN WHAT THEY NEED AND WHAT THEY CAN AFFORD

Some people sock money away in a 401k to buy a home or save for retirement. Over the five years she worked for a Chicago-area electronics corporation, Rachael Zuniga amassed a nest egg of $20,000. Now she's used her savings to cover the bill for the gender-reassignment surgery she had scheduled for May 4.

Zuniga is one of the lucky ones. She's cleared one of the biggest hurdles in making a gender-related transition. "Otherwise, I couldn't afford it," says Zuniga, who now works as an administrative assistant at Howard Brown Health Center, a gay and lesbian community health agency in Chicago.

But there have been some lean times. Zuniga, who was born a biological male, estimates that since she started making the transition a few years ago, her credit card bills have topped $15,000. She had 200 hours of electrolysis--costing from $30 to $65 per hour--to eliminate facial hair. Since her insurance didn't cover the cost, she says, she could afford the treatments only by putting gas, rent, and other living expenses on a credit card.

"There were times that I didn't eat properly for a few months [and times] I paid less money on bills than I should have," Zuniga says. "I ended up going a lot into debt because this was so important. I'm going to spend 20 years paying off what I've already spent."

Before they invest any money in health care, transsexuals such as Zuniga often spend years, even decades, of their lives sorting out the complex internal and social issues associated with their gender identification. But once they've grown to understand themselves, told their families and friends, and begun living as their self-identified gender, they also must be prepared to face enormous medical expenses.

"It's another thing that makes you feel way out there and isolated and alone," says Michael Munson, a female-to-male transsexual computer consultant living in Milwaukee. "It adds to that feeling of isolation."

For most, that means going it alone to pay for the treatments and surgeries themselves. That's because most insurers do not provide reimbursement for transsexual surgeries, which they consider elective--"even though you may be ready to blow your brains out because your body doesn't match your brains," says Alex Dionne, a female-to-male transsexual who lives in Cambridge, Mass., and who asked that his real last name not be used to protect his family's privacy.

The cost of transition-related health Care includes a wide range of services and treatments. Male-to-female transitions can cost anywhere from $18,000 to $35,000, while female-to-male reassignments are far more expensive since a phalloplasty (in which a phallus is created, typically from the patient's forearm tissues) alone can run up to $50,000. Other services include psychotherapy, hormone treatments, and a variety of surgeries. Add to that other incidental expenses for everything from legally changing one's name (about $200, depending on the state) to buying a new wardrobe (one female-to-male patient needed to replace $2,000 worth of boots when, according to him, his feet grew because of hormone therapy).

Insurers typically pick up the cost of psychotherapy, and doctors are usually able to get reimbursed for hormone treatments--but only because they are deliberately vague in reporting their purpose. One doctor who sees many patients for hormone therapy refuses press interviews because, according to an assistant, he fears his records may be scrutinized.

Activists are divided over the best way to proceed with lobbying for access to reimbursement for transsexuals' medical care. Some advocates would like to shift the debate from the psychiatric arena to the medical field by pushing for the American Psychiatric Association to end its classification of gender identity disorder as a psychiatric problem. While that may provide better footing in achieving broader civil rights for transgendered people, it also could undermine their ability to make progress with insurers, advocates say.

Alejandro Daviko Marcel, director of the Transgender Education Network, a state-funded agency in Boston, says he has never heard of an insurance company paying for reassignment surgery. In fact, he says, he would advise pre-op transsexuals to consider carefully the repercussions of asking an insurer to pay for anything related to their transition, even if their doctor doesn't specify the reason for the treatment.

"It really puts your health credentials on the line with insurance companies," Marcel says. "If the insurance company covers it, then from there on you're marked as someone who's had this surgery, and everything that follows, healthwise, will be under question [as to] whether it relates to sex-reassignment surgery."

In February the state of Oregon decided against adding sex-change procedures to the list of approved health services covered under the state's health plan for the poor. Transgender advocates had urged the Oregon health services commission to extend coverage to include the procedure, but the state panel ruled that there was no good evidence showing that sex-reassignment surgery improves patients' mental and emotional well-being or socioeconomic status or that it reduces the incidence of suicide attempts among transsexuals.

"I'm hoping that some day in the very near future, insurance companies will relent," Zuniga says. Until such a breakthrough, transsexuals will have to rely on their own means of support to pay for their health care. Many people find it a tough emotional strain when they know surgery is available but can't afford it. The costs play a crucial factor in determining the amount of surgery an individual can have done and when those procedures can be completed.

Some must wait and thereby make adjustments in their lives. Munson points to a friend who works a low-wage job in a cafe and can't afford surgery. The friend, a female-to-male transsexual, tries to disguise his breasts by binding them, wearing dark colors, and adopting a slumped-over posture. Munson, however, who founded a female-to-male support group in Chicago called For Ourselves: Reworking Gender Expression, says he's a strong advocate for people's "evaluating what's necessary in their lives, what they want to do with their bodies versus what they need to do with their bodies." After taking hormones and having surgery to remove breast tissue, the friend has decided to live with his body as it is now.

Munson suggests other paths for people who don't have the money or don't want to spend it. "We spend a lot of time thinking about men and women, and most of it doesn't have to do with what's between our legs and what our physical bodies are like," he says. "I think a lot of people jump through hoops thinking [surgery] is what they have to do. You can be a very healthy, very wonderful man without having genital surgery."

Many of those who pursue surgery must be financially creative. Some ask relatives and friends for help, take two jobs, or refinance a house. When his company's insurer wouldn't cover the cost of his recent chest surgery, Dionne took out a personal loan at the company's credit union. He says he plans to complete the rest of the surgeries but doesn't know how he'll pay for them. So now he's writing a screenplay about his life that he hopes to sell.

"It's kind of similar to a couple's getting ready to have a baby," Dionne says. "You go through all this financial and emotional preparation for what's to come. You really have to strategize."

Add to that the cruel irony that employment can prove another challenge for transgendered people. They may have difficulty securing a job if they are already living as their self-identified gender, or they might be fired since most civil rights laws do not protect them.

Some male-to-female transsexuals turn to prostitution. Dee Teixeira, a hairstylist in Los Angeles who is a pre-op male-to-female transsexual, says she has known people who took to the streets as a way to try to save up some money. "The next thing I know, they're strung out on drugs, they haven't saved any money, and they're in jail," she says.

Others choose to go out of the country to find lower-cost surgery. Thailand has become a popular destination for surgery, but Teixeira says some of her friends haven't been completely satisfied with the results and needed additional corrective surgeries.

In the end, people in transition say the sacrifice and the savings are well worth it. "This is something you have to do on your own," Teixeira says. "You just have to hang in there. I'm definitely going to get it done--there's nothing that's going to stop me."

RELATED ARTICLE: HOW IT'S DONE

Sex-reassignment surgery can include a series of many difficult and expensive procedures. While being a transsexual does not require that all (or any) of these surgeries be performed, the following reassignment surgery procedures are options for transsexuals:

MALE-TO-FEMALE

VAGINOPLASTY: Involves removing the testicles and the inside of the penis and then inverting the penis skin to create a vagina.

ADAM'S APPLE SHAVING: Surgery done under local anesthesia to decrease the size of the Adam's apple.

VOICE SURGERY: Procedure that scars the vocal chords to modify the voice's pitch.

BREAST AUGMENTATION: Saline-filled implants are inserted under the existing breasts.

FEMALE-TO-MALE

BILATERAL MASTECTOMY: The removal of breast tissue and reduction of nipple size to form a male chest.

PHALLOPLASTY: Construction of a penis using skin, nerves, veins, and arteries from other parts of the patient's body. The labia may be used to construct the scrotum. Clitoral nerves are usually preserved and may eventually grow into the new penis. Testicular implants and implants to obtain an erection can be inserted in subsequent procedures. Urethral extension is also possible.

METAIDIOPLASTY: An individual whose clitoris responds sufficiently to testosterone may have the clitoris released from its hood and the shaft "finished" along the bottom side, completing the foreskin. The resulting small penis is also raised about one centimeter forward on the body. The labia are also raised and fused in the center to form the scrotum through use of testicular implants. This procedure retains natural erectile capacity. The patient can elect to have the vaginal cavity closed and/or the urethra extended through the penis.

HYSTERECTOMY/OOPHORECTOMY: The removal of female reproductive organs and gonads.

--Jon Barrett

RELATED ARTICLE: DR. COMPASSION

ONE SURGEON'S WORK HAS MADE RESIDENTS OF A SMALL COLORADO TOWN EXPERTS ON TRANSSEXUALISM BY LISA NEFF 

Each week two or three people take the "road to Trinidad" to meet the doctor of their dreams--Stanley Biber.

Biber is one of the world's leading gender-reassignment surgeons. His pioneering practice has drawn more than 4,000 people to the town of Trinidad, Colo., to undergo gender-reassignment surgery over the past 30 years.

Biber performed his first reassignment surgery in 1969 after a social worker, who brought her children to his office for checkups, asked, "Can you de my surgery?" Says Biber: "I said, `Sure, what do you want done?' She said, `I'm a transsexual.' I said, `What is that?'"

Biber quickly learned the definition of transsexual and, guided by drawings supplied by a surgeon at Johns Hopkins Hospital, performed his first reassignment surgery--a penile-scrotal flap, or inversion of the organs.

In the three decades since his first operation, Biber has performed 3,800 male-to-female procedures and 350 female-to-male operations in Trinidad's 70-bed Mount San Rafael Hospital. "The grapevine is so strong," he says.

Gender-reassignment surgery accounts for only about 20% of Biber's practice, but the doctor who lacked a knowledge of transsexualism in 1969 understands very well the arduous journey his patients make.

"You develop a lot of empathy for these patients," he says. "These people have been in hiding all their life. They've been hit on the head so many times before they come here."

Biber came to Trinidad in 1954 to work at a United Mine Workers of America clinic after serving as an Army surgeon in the Korean War and at Fort Carson in Colorado Springs, Colo. "I thought I'd be here for a year or two," he recalls.

But Biber remained, building his practice, raising a family of nine children with his wife, and operating a cattle ranch. "I get out in the open country and chase my little cows around," says Biber, whose devotion to ranching is equal to his passion for surgery.

As Biber's reputation as a surgical pioneer has grown, so has the fame of Trinidad. Situated on the front wall of the Rockies about 200 miles south of Denver, Trinidad emerged as a wild cattle town in 1842. Today, with a population of about 9,000, Trinidad is still the Old West. Brochures promote the town as "a pocket of peace, plentiful clean air, and pure Western Americana."

But Trinidad also is known as the "sex-change capital of the world." Biber chuckles at this moniker as well as the nickname so many of his patients adopt for themselves--"Biber girls." "That doesn't emanate from us," he says of the nicknames. He then asserts that Trinidad is not ashamed of his work or its contemporary claim to fame.

"My people are so sophisticated," Biber boasts of Trinidadians. "They're all experts on transsexualism. They understand better than anybody in the world because they live with these people. The understanding came from exposure."

Neff is national news editor at Chicago's Windy City Times.

Savage is a regular contributor to the Chicago Tribune.