City of SF to pay for sex change ops?

The San Francisco Board of Supes is considering whether the city’s health care coverage (for city employees) should include sex change operations. (I haven’t yet found a good link to an article yet). One supporter I heard on KQED radio this morning said that denying these costly operations (~$70,000) is discrimination. It seems to me that it isn’t much different than cosmetic surgery.

I’m not expert on sex changes but I’ll take put in my two cents worth. A sex change operation is a lot more then just simple cosmetic surgery. It involves years of psychological and physical procedures. I believe that someone must live for a year as that gender before an operation can occur. During this time they might be taking hormone therapy or undergoing other procedures.


As to whether or not the city should pay for it…beats me.

True, the procedure is more intensive than cosmetic surgery. But it is still elective surgery that changes the appearance and body structure of the patient. While the patient might be more comfortable in their ‘new’ body, one can imagine that a woman might decide that she’d feel more comfortable with different sized breasts. Or someone else might like a nose job. Should the city then pay for these, too?

Big Daddy, the parallels you’re attempting to draw are not on all fours with the situation from your OP. Yeah, I would look much better with cosmetic surgery, but I’ve learned to live with a less-than-attractive appearance all my life.

I will grant that a sex change operation is true elective surgery, but it would fall into a similar category with the sort of surgery that needs to be done sooner or later but need not happen at any particular time – the original, pre-cosmetic definition of “elective surgery.”

I rather hope pldennison happens on this thread, because he has far more background information at hand on gender dysphoria than my casual reading will provide.

But in short, what you have in such cases is a real case of that old joke, “a woman trapped in a man’s body” or the reverse. In short, the person feels him/herself to be an individual of the opposite sex than the outward organs would indicate. (And, rarely, is “somatically correct” – is in fact an XX female by genetics who developed male organs, or an XY male genetically who developed female ones, or the results of a ob/gyn guessing wrong at assigning sex to an intersex baby.

There was a thread over in IMHO about what one might do if one were the opposite sex, largely for laughs. But the number of responses to it indicates to me that most people are capable of imagining what it would be like to be the opposite sex from what they are. Put yourself in that position. Then imagine that, rather than doing it for an exercise, you really believe yourself to be that sex, but with the wrong bodily equipment and structure.

Rather than going through psychological therapy to correct this mental attitude about which sex he/she ought to be, the gender-dysphoric opts for hormonal treatments, surgery, and various other things (including mandatory counseling) to correct the body to what the inner self feels it ought to be.

Phil? Transsexual lurkers? Please correct what I got wrong here.

Poly- I’m sure that transgender issues are hard to deal with. My questions are these:

Is surgery absolutely necessary? Would hormone therapy or other solutions be enough?

Is the city’s lack of coverage tantamount to discrimination? We’ve all had difficulty figuring out our sexuality. Is having a fully resolved sexuality a right? Is denying coverage for surgery impeding transgedered people their rights?

If so, where is the line drawn? E.g., a woman might that she’s had a hard time coping with AA breasts- should she have subsidized implants?

Since there’s such controversy over taxes covering things like birth control and abortion…or is that already done there?

I guess it would depend on the cost. Could it be afforded, without detriments to other areas, and no one abusing it?
Like someone opting for nose jobs and the like?

I know these are covered in under most Canadian provinces’ medical plans. Its a recognized treatment for gender identity disorder as they call it. In general, even without a recognized disorder, a treatment designed to correct a situation which causes extreme psychological distress will be covered here.

Its easier for us, in cases like this, to understand that the expense of treatment has to be weighed against the severity of the problem and eficacy of alternate treatments. Ontario recently decided to stop funding these cases, I know an action was filed but I am unaware of any progress in the case.

I understand that they had about 11 gender reasignments per year (in a population of 11 million) at a cost of about $120,000 (Canadian dollars but likely the same in US down there).

what if one you guys grew breasts?? would you expect your medical insurance to cover treatment for it??

if a gal out there sprouted a penis, would you not expect visits to the doctor to be covered??

i suppose that is how a so-called transsexual feels about things.

This is actually a pretty tough one for me. I’m not transgendered, but a Very Very Close friend of mine is- so I tend to be extremely supportive of TG issues in general. Assuming you get the full range of treatment that’s usually required even before most doctors will consider recommending SRS, you’re out possibly as much as $20,000 over 2 years- that’s a big bite for anyone’s wallet, and I have to sympathize.

OTOH, I’m also of a fairly libertarian bent, so I definitely have to examine the whole “excess expenditure” thing here - there are certainly plenty of taxpayers in SF who didn’t sign on for the chance to have their money used this way.


  1. I’d like to start by dispensing with the “eew, gross” objection- the idea that public policy should be determined by subtracting every single thing that has ever disturbed anyone from the realms of polite discussion. That idea is noxious to just about any sort of reasoned discourse; it’s not going to help here. In general, therefore, I don’t feel that some social conservatives’ objection to even the acknowledgement of transgenderism should stop any other group of people from discussing it, provided the conservative objections are duly noted (and in my case, at least, dismissed).

  2. Now, then, we have to define what, exactly, we’re talking about funding here. Most doctors who perform SRS will insist on following the HBIGDA Standards of Care, including psychological counseling and evaluation, hormone treatments, and only then SRS. In addition to the minimal surery, many transsexual individuals will want additional cosmetic reconstruction- whether it’s laser hair removal, breast implants, etc. Therefore, we’re really talking about four different areas of treatment that might be covered separately for insurance purposes. I have yet to see a detailed explanation of which parts San Francisco is proposing to cover.

  3. Here’s the big important part: I don’t actually know the exact structure of San Francisco’s current insurance plan. If it’s a full coverage benefit (i.e., the cost of premiums for the plan is covered entirely by the city), then the additional cost of paying for the possibility of providing that $20,000 dollar course of treatment is going to be borne by the taxpayers and city employees. It’ll be there in the form of higher taxes, money diverted from other city expenses, and money removed from the city payroll fund at the expense of raises or new hires. If, on the other hand, the cost is mostly borne by the individual employee, the economic impact will be much less on the city as a whole.

  4. Now that wer’re on the same page, here’s my take on the matter.
    First off, I’m mostly in favor of “pick your coverage” plans. Everyone’s familiar with the concept of paying extra for dental insurance or coverage of your children. Were *I * in charge of the city’s insurance, I’d require all employees to pick various areas of coverage they wanted, and then split the cost between the city and the employee. That way, any employee has an incentive not to cost themself extra money, so they have an incentive not to cost the city money. While I’m not such a utopian as to think that this will actually happen, most of the things which we’re discussing fall into general categories along with some non-controversial treatments, and ought to be covered on not-covered along with them.

Psychological counseling: ought to be paid for, if the city pays for it in other purposes. Again, there’s no grounds for the “eew” factor in determining appropriate medical treatment. If it’s not covered now, and the city wishes to cover it for SRS purposes, they should likewise be covering it in general.

Hormone treatments: Again, if the city covers hormone treatments for endocrine disorders, there shouldn’t be a problem with covering them for transsexuals. In particular, if they cover hormone replacement for postmenopausal women, they can certainly choose to cover it for other people with a lifelong need.

Cosmetic procedures (as in the vocal surgery, laser hair removal, etc.): pay for them your damn self :slight_smile: If they aren’t gonna pay for women’s vanity treatments, they shouldn’t pay for men’s.

Okay, now for the Big One: should they pay for the actual Main Event? My answer is that yes, as long as they’re willing to back up their social statement (which is what this is) with common sense numbers. I don’t think that they anticipate a flood of transsexual applicants for civil service jobs, but they need to consider the possibility. More to the point, they ought to be willing to pay for it entirely with an acceptably small reduction in payroll. If the money has to come from elsewhere, they shouldn’t be covering it. Common sense.


“Hard” doesn’t even begin to cover it. “Life-altering” might be a better starting point.



A matter of opinion. Personally, I think it ought to be covered, 'cause it’s not like anyone’s going to take advantage of it.

Everyone has a right to be the whole person they feel they were meant to be. Whether or not the state should subsidize that journey is open to debate, obviously.

Maybe, maybe not - that’s an issue for the legal system, I’d wager.

You’re comparing apples to oranges, IMHO. As Poly pointed out, it’s not like sexual reassignment is a walk in the park - it’s a very, very serious, down-to-the-core-of-your-being issue. And sexuality, gender, gender identity, sexual orientation, and sexual identity are, as hard as it might be to grasp, all related but nonetheless seperate issues. Took me a long time to wrap my mind around that concept.

Go check out The American Psychological Association for a more learned point of view.


In some cases, hormone therapy is enough; in others, it is not. Gender dysphoria and transgenderism take many different forms.

The situation here, however, is the situation where a doctor, following generally accepted medical and psychiatric guidelines, has determined what course of treatment is in his or her patient’s best interest, but the patient is unable to obtain that course of treatment because an insurer refuses to pay for it not because the treatment is “experimental” (it’s not) or “unproven” (it’s not) but because it’s politically unacceptable. That’s the situation with sexual reassignment.

Does this answer your question about “Is the city’s lack of coverage tantamount to discrimination?”

I might also note that transsexuals who are unable to obtain reassignment have something like a 25% suicide rate, and over half are clinically depressed. Many are unable to function economically at anywhere near their capabilities. Reassignment in accordance with the Standards of Care has something like a 95% acceptance rate and postoperative individuals almost invariably lead happier, more productive lives. You tell me if it makes sense to deny treatment.

One other point: federal law requires states to pay for reassignments for indigents on Medicaid where the patient has been diagnosed in accordance with the Standards of Care. However, states generally refuse to do so without a court order. I’ve seen at least three federal cases on this point so far, one in Iowa and two in Texas.