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Tori Rotschafer says she is caught in a twilight hell. Until 1997 she was John, a man who longed to be a woman. Now, after four years of female-hormone therapy, she dresses and presents herself publicly as a woman and needs only surgery to complete her transformation. For 3-1/2 years, the Kaiser Foundation Health Plan of Georgia, Rotschafer’s health maintenance organization, financed the drugs and therapy that provide a long prelude to the surgery that completes the sex change. Then, last November, Kaiser told Rotschafer it had paid for the services in error. It would no longer pay for anything connected to the sex change. “We understand you have received some of these services in the past; however, they were paid in error,” the letter from Kaiser stated. Without insurance, Rotschafer, now 50, could not afford the operation, which could cost as much as $120,000. Kaiser attorney R. Hal Meeks Jr., a partner with Pursley Lowery Meeks, says Rotschafer’s HMO contract with Kaiser is clear: Kaiser does not pay for sex-change operations. “Kaiser’s point of view is a very straightforward one. They have a written contract that defines benefits. Transgender surgery is expressly excluded as a benefit … and the law does not provide for oral waiver or oral modification,” he says. Kaiser may have covered the cost of Rotschafer’s psychotherapy and hormone treatments, he acknowledges. But confidentiality regulations governing mental health care shield the exact nature of that treatment and prevented Kaiser from knowing that Rotschafer was pursuing a sex change, Meeks says. “Kaiser did not knowingly pay for treatment that would lead to transgender surgery,” he says. Nor did Kaiser knowingly pay for hormones for the specific purpose of preparing for transgender surgery, he adds. “Once it was discovered this was the purpose of the prescription, they ceased providing those medications,” Meeks says. But as a result of those treatments, Rotschafer now has a female’s breasts and a male’s genitalia. “I’m a freak,” she says. “You’re not a freak,” responds 37-year-old Gwen Rotschafer, Tori’s wife of 20 years. “You’re stuck in the middle.” ‘STUCK IN THE MIDDLE’ Tori Rotschafer is suing Kaiser for damages resulting from her incomplete metamorphosis. “I want them to finish what they started,” she says. The claim was removed from Cobb County, Ga., State Court to U.S. District Court in Atlanta last month. Rotschafer v. Kaiser, No. 1:01-cv-0990 (N.D. Ga. April 19, 2001). Roy Mullman, Tori Rotschafer’s attorney, says the case is not simply a gender reassignment issue. The case questions whether an HMO can stop ongoing treatment for a medical condition after initially paying those benefits. “We’re not only here fighting for gender reassignment [coverage],” Mullman says. “For people dealing with any type of insurance, it’s an issue when, once you’ve gone through hell, they cut you off at the knees.” Moreover, Mullman says he intends to prove that Rotschafer’s experience is part of a pattern by Kaiser in which the HMO initially approves medical procedures only to deny coverage when continuing treatment becomes too expensive. “We believe this case will show a pattern as to how they [Kaiser] treat their insureds and made a lot of money doing it,” he says. In this case, Kaiser’s alleged change of mind leaves its client in a medical limbo. Rotschafer can’t simply stop taking the female hormones and revert to her male body. The breasts produced by the hormones are permanent and can be removed only surgically. And after four years of loading her body with three times the estrogen found in most women, “It would really be unhealthy without medical supervision to go off of them,” she says. “The cost to go backwards is as great as the cost to go forward.” CONTINUING ON Rotschafer still wants to go forward with the sex-change surgery, as was her intention when she changed her name and “came out” in 1999. She refers to the surgery as “an adventure” and the male genitalia she intends to have amputated as “a cancerous growth.” But, she says, she never would have agreed to undergo hormone therapy and “come out” as a woman if her Kaiser facility had not assured her that Kaiser intended to pay the bills. Meeks says Kaiser has no obligation — despite its erroneous benefit payments for Rotschafer’s hormones and therapy — to pay to complete Rotschafer’s transformation. “The first time she made an inquiry to member services if Kaiser would pay for this, she was told clearly, ‘no.’ “ “The patient is certainly free to have transgender surgery if he or she chooses to do so,” Meeks continues. “My clients are not doing anything to prevent the patient from having surgery. We just have a written contract that makes clear we’re not required to pay for it.” Says Meeks, “It would be a terrible precedent for the court to find the provision of benefits not covered under the four corners of the policy imposes an obligation to provide additional benefits which are not contracted for. … Essentially, insurance wouldn’t be a matter of contract anymore. … It would price insurance so high that nobody could afford it.” KEEPING THE SECRET Tori Rotschafer says she has known “pretty much all my life” that she wasn’t meant to be a male. But it was a secret she says she kept through her childhood as a boy, through nine years of military service — including a stint in Vietnam — through a job as a rehabilitation psychologist working with handicapped adults, and into her first marriage. That relationship ended when she told her first wife she would rather learn to sew and “do girl things” than hang out with “the guys.” In 1979, Rotschafer met Gwen “and made a match where I could feel secure.” Before they married, Rotschafer says she told Gwen that she was a woman trapped inside the body of a man and that she wanted something she knew she could never afford: a sex-change operation. “I always thought she was my soul mate,” says Gwen Rotschafer, who came out as a lesbian a year ago on the “Sally Jesse Raphael Show.” “Actually, I thought it was something we could work through.” Tori Rotschafer says after their wedding, she assumed the role of housewife while Gwen “became the more dominant of the two.” Rotschafer says she embraced housework, cooking and child care for a family that eventually would include three children. She says she often wore women’s clothing around the house and a nightgown to bed. When their first son was born, “I got to play Mommy,” Rotschafer says, even though she still looked like a man and her children — a girl and two boys — called her Dad. “I loved it.” Gwen began calling her “Samantha,” shortening it to “Sam” whenever they were in public. The couple says they didn’t need to tell the children about Tori Rotschafer’s gender issues. “They just knew that Dad was different,” Gwen Rotschafer says. Says Tori: “They also knew it was something not be taken outside the family.” Tori Rotschafer says she gave up psychology for a career as a computer programmer in Atlanta. It was that job that eventually would open the door for a sex-change operation. ‘COMING OUT’ Tori Rotschafer says she has a temper and that, for years, displays of anger marked her relationships. She says she learned through counseling that her anger stemmed from the secret that she hid from everyone except her wife and children: She wanted to be a woman. It was also at the root of her drive to change jobs every two or three years so people wouldn’t discover her secret. “The more macho I was, the more angry I became,” she says. In 1997, Tori Rotschafer says, her supervisor referred her to a counselor at Kaiser, the company’s HMO, for anger counseling and stress management. Asked by the counselor in a joint session with Gwen why she was so angry, Rotschafer — then still known as John — replied, “I can’t be who I really am.” The counselor referred Rotschafer to a psychologist and family therapist who specialized in sexual therapy. Rotschafer says that psychologist — a past chairman of the Georgia Composite Licensing Board, for social workers, professional counselors, and marriage and family therapists — told her she was an ideal candidate for hormone therapy and an eventual sex-change operation. Gwen was supportive. “I like Tori a lot better than I did John,” she says. Two weeks after the first therapy session, Tori Rotschafer says, the psychologist and her personal physician — a member of Kaiser of Georgia’s governing board — told her Kaiser had agreed to pay the bills for a sex change. She began taking estrogen in April 1997. Kaiser paid the bulk of the cost of hormone therapy, which could run as much as $300 a month. Tori Rotschafer says she paid only a $5 co-payment for each refill. Without reassurances that Kaiser would pay for the complete process, Tori Rotschafer says, she never would have started it. Eventually, she had to come out as a woman to her family, friends and co-workers. That decision led Tori Rotschafer’s parents and grandparents to sever all ties to her and made her an object of derision at her office. When her mother told her she would rather have her die than live life as a woman, Rotschafer says she attempted suicide by swallowing an overdose of Ativan. She fell asleep before she could finish the bottle. “It was a long road,” Tori Rotschafer says. “I never, ever would have begun that process if I knew Kaiser wasn’t going to finish it. … People [who have done it] have lost marriages, families, homes, children. It’s not a process you go through unless you finish it. It’s a process that, once you start, there is no going back unless, like me, you are trapped in hell.” In the spring of 1999, Tori Rotschafer says her psychologist gave her final approval for the operation. She and Gwen began planning for the surgery the following year, after a full year of living publicly as a woman. She says she had no qualms about the finality of the surgery. “Slice it, dice it, and stuff it,” she says. But in the fall of 1999, her firm was sold and the new owner contracted with another medical provider. Tori Rotschafer tried to maintain her medical coverage with Kaiser, and the HMO balked. After telling her it would no longer pay for the sex change process, Tori Rotschafer says the HMO dealt another blow. It refused to insure her and declared her uninsurable because of her transgender status. That made it almost impossible to pick up health insurance from another company. Meeks disputes Tori Rotschafer’s account. He says he has never heard the allegation that Kaiser declared Rotschafer uninsurable. “I do not believe that to be the case,” he says. Meeks also says that Tori Rotschafer elected to discontinue her Kaiser coverage when she found out it wouldn’t cover the sex change. But Tori Rotschafer says her new company “used the Kaiser pull-out as a reason to make my life hell,” she says. “I finally resigned.” “We were devastated,” Gwen Rotschafer says. It was, echoes Tori Rotschafer, “more crushing to me than my parents’ rejection. … I felt my candy had been stolen. I felt my family had been stolen. I felt my whole life had been stolen from me.” Now Tori Rotschafer says she lives “in a kind of twilight zone” while she continues to prepare for surgery that she cannot afford. She is still taking hormones but is paying the full pharmacy price. She has continued living and dressing as a woman, and will soon begin a new job as a teacher at a private school for youngsters who are struggling with their sexual identities. She is finishing a book that she says Random House plans to publish called “My Journey of Discovery” about her sexual transformation. Her life, she says, has taken “this fantasy twist. It’s become a constant costume ball.”

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