At 10 years of age, Chris (his name has been changed for privacy) became convinced that something was deeply amiss. He was a boy, but his body looked like a girl. What he saw in the mirror and what he felt inside were profoundly at odds. Growing up in rural Texas in the 1980s, he knew it didn’t matter how he felt; in society’s eyes, he looked like, and therefore could only be, one thing: a girl.
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August 2023Bullying, violence, and even sexual assault ensued as Chris navigated puberty, high school, suicidality, and a deepening isolation. Whisperings of a faraway haven in California, where boys could be boys no matter what they looked like, gave him hope. In college, he discovered the LGBTIQA+ community and initially came out as lesbian before realizing his identity as a trans male. Inspired by trans male rapper Katastrophe, who transitioned in San Francisco, Chris decided to follow suit.
San Francisco, a city in California considered the land of opportunity, had its drawbacks. A prohibitive cost of living left Chris undomiciled and lining up in front of shelters every night. Trans life in a shelter was much like his childhood: plagued with violence, sexual assault, and transphobia.
Despite the challenging circumstances, however, there were several beacons of hope. California’s universal healthcare insurance system provided access to testosterone therapy, finally enabling Chris to initiate his transition. For the first time, his dysphoria began to ease. But it was only the beginning.
Several years later, Chris’s insurance approved and covered his gender affirmation surgeries, including mastectomy, hysterectomy, phalloplasty, and finally facial masculinization surgery with Rahul Seth, MD, at the University of California, San Francisco Facial Plastic and Reconstructive Surgery. With newfound confidence, Chris turned his sights toward giving back. He lobbied the city to help start Jazzie’s Place, San Francisco’s first LGBTIQA+-specific shelter. He also successfully led an effort to obtain insurance coverage for phalloplasty and was the San Francisco Medicaid program’s first patient to have the procedure covered.
Advances in Access to Care
Access to gender affirmation care and surgery in California has evolved over the past two decades and has set precedents for the rest of the nation. Prior to 2013, transition-related surgeries were not covered by insurance in the state, but since then, a multitude of state-based legislative actions have dramatically improved access (see Table 1). A selected few are discussed here.