"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.
"One of my earliest memories is of wearing my sister's dress to school when I was 6," recalls Dunne, who grew up as Robert Francis Dunne in Menlo Park. "When I tried to play in the sandbox, I got in a fight with the other boys and they ended up ripping off the dress."
Dunne says she always knew she was different, but wasn't sure exactly how. For many years, she tried to think and act like a man. She took testosterone supplements and grew a scratchy beard. She married three times, but all three marriages ended in divorce.
"I collected wives for a while, but they were more like hostages," Dunne says ruefully. "None of my marriages worked out because we all wanted the same thing and couldn't give it to the other person. I really tried to act like a guy, to do guy things. I'd say things like (deepens voice), 'Hey, let's go out to the garage and take a look at that car.' "
Dunne even chose the most he-man profession around -- construction work. She's been a sheet-metal worker since 1968, advancing to become a well-regarded foreman. She began taking estrogen about three years ago, and mulled going through with sex reassignment surgery, but her hand was forced when she was "outed" by a co-worker in 1993 who had noticed early changes from the hormone treatment. Shortly thereafter, she was laid off, and filed a discrimination complaint against her former employer, Foothill Air Conditioning and Heating of Los Gatos. But the state Department of Industrial Relations ruled that since she was transgender and not gay, she wasn't protected under the state's anti-discrimination laws.
In November 1994, Dunne underwent a sex-change operation, knowing her union insurance would pick up the tab. The total cost of her initial surgery and two subsequent procedures is now more than $70,000, on the high side because she had the work done at pricey Stanford Hospital. (Coincidentally, as a sheet-metal worker in the 1980s, she helped build the operating room at Stanford where she later had her sex change.) Dunne concedes that she could have had the same procedure done at a surgery center for about half the cost. In response to her operation, Dunne's local union, the South Bay Sheet Metal Workers, came out with a revised health care plan that specifically excluded coverage for "services associated with sex transformations and resulting complications." Up to that point, it never occurred to anyone in the union that a sheet-metal worker would want a sex change.
Cost, not surprisingly, is the major concern to insurers who would have to foot the bill if San Francisco's proposal becomes law. The city's Health Service System Board is studying the likely costs of the proposal, after which the seven-member panel will put it to a vote. The measure would have to be approved by the supervisors and signed by the mayor before becoming law. The city would then have to negotiate with insurance providers to remove the sex-change exclusion from health policies.
In 1994, the city passed an ordinance making it illegal to discriminate against anyone on the basis of gender identity in housing or employment. Supervisor Ammiano calls eliminating the sex-change exclusion in health plans "the natural next step."
According to the San Francisco Transgender Community Task Force, the city is home to an estimated 6,000 transgenders, which includes transsexuals (whether or not they've had surgery), cross-dressers (the currently preferred term for transvestites), and hermaphrodites (those born with both male and female sex organs). Of that total, only about 500 city residents are transsexual. (A recent Associated Press wire story mistook all transgenders for the much smaller subset, putting the number of S.F. transsexuals at 6,000, more than 10 times the estimated number.) Seven city employees are openly transsexual, out of a work force of 25,000. But it's unclear how many city workers -- or their family members, who would also be covered -- would elect for surgical reassignment. Insurance companies would pick up 80 percent of the tab for a sex change, the standard payment for medical procedures in the city's health plan.
Dunne counts herself lucky to have had a health plan that covered sex-change surgery, even unwittingly. And she strongly supports extending the same coverage to San Francisco city workers.
"I think it's very important," Dunne says. "It's a medical condition pure and simple, and it needs medical attention. For me, it was the best thing I could have done. I've never been happier.