A transgender woman in Oregon has filed a $375,000 lawsuit against her insurance companies and her employer, saying they’ve discriminated against her by refusing to pay for facial surgery that would make it more likely that strangers would perceive her as female.

Christina Ketcham, a 59-year-old Clatsop County employee, has already undergone sex reassignment surgery, hormone replacement therapy, worked with a voice coach and changed her name, clothes and hairstyle to reflect her gender identity, but her doctors also recommend that she undergo “facial feminization surgery” to continue on that path.

It could include rhinoplasty, reduction of her facial bones, a face lift and an eyelid lift.

Her doctors have determined the surgery is “medically necessary” to treat Ketcham’s gender dysphoria. She was diagnosed with gender dysphoria four years ago but has experienced it since childhood, according to the suit.

But from 2016 to 2019, Citycounty Insurance Services, which provides coverage to Clatsop County employees, and Regence BlueCross BlueShield of Oregon, which administers the plan, have turned down Ketcham’s request to cover the cost of the surgery, the suit says. Representatives from Citycounty Insurance Services and Clatsop County didn’t respond to requests for comment.

Jared Ishkanian, a spokesperson for Regence, said the company couldn’t discuss the pending litigation but supports "our members with comprehensive, medically necessary transgender services.”

Ketcham has worked for Clatsop County for nearly 30 years, the suit says. She has worked for the county’s fisheries project as a “fisheries biological aide” for 17 of those years.

She has suffered ongoing distress as she has waited for her insurance to fund her facial surgery, her lawsuit says.

“Ms. Ketcham continues to be perceived by others as male,” states the suit, filed July 18 in Multnomah County Circuit Court. “Her facial features and the shape of her face frequently lead others to call Ms. Ketcham ‘sir,’ ‘mister’ or ‘he-she,’ and to treat her as a man.”

The surgery, depending on what is done, can cost between $20,000 and $40,000, said Asaf Orr, one of Ketcham’s lawyers and a staff attorney for the National Center for Lesbian Rights in San Francisco.

“Facial feminization surgery is hugely transformative,” Orr said.

Lawsuits such as Ketcham’s are rare, he said. Orr tracks this area of legal practice and said Ketcham’s suit is the only active one he knows of in the nation. In early 2018, the National Center for Lesbian Rights was involved in successfully pushing the Oregon Health Plan to cover a facial feminization surgery for a transgender woman, Orr said.

Transgender people used to frequently have to fight insurance companies to pay for gender reassignment surgery, he said, and now the surgery is more widely covered. The legal battleground has shifted to areas such as facial feminization or facial masculinization surgeries for transgender women and men, he said.

The suit says Regence “categorically excludes coverage of facial-feminization procedures” by “wrongly deeming them ‘not medically necessary’” as a treatment for gender dysphoria. But the suit says Regence covers procedures such as eyelid lifts and facial bone reduction surgeries for reasons other than gender dysphoria, and those include ingrown eyelashes and to correct jaw deformities.

The suit alleges that the reason for denying the surgery for transgender patients is “a reflection of animus toward, or an intent to discriminate against” transgender people. The suit asks a judge to permanently order the defendants to stop categorically denying facial feminization surgery as a treatment for gender dysphoria.

According to the suit, the World Professional Association for Transgender Health states that facial feminization surgery, along with other gender confirming surgeries, “are not ‘cosmetic’ or ‘elective’ or ‘for the mere convenience of the patient.’” Major health professional organizations -- including the American Medical Association and the American Psychiatric Association -- support that position, according to the association’s website and the lawsuit.

The suit says Ketcham has “struggled with this feeling of incongruence” about her gender identity for much of her life.

“At birth, Ms. Ketcham was assigned male, but as early as childhood she understood she was a girl,” the suit states.

“As a young person, Ms. Ketcham’s family and community did not provide any support or options for her to live as a woman consistent with her gender identity,” the suit continues. “As a result, she spent most of her life trying to conform to male stereotypes and living outwardly as a man, despite the severe emotional distress this caused her.”

Ketcham is being represented by a team of attorneys, including Orr and Portland lawyers Talia Guerriero and Christina Stephenson.

-- Aimee Green

agreen@oregonian.com

o_aimee

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