When it comes to transgender benefits in Oregon, all things have not been equal.

While transgender men can choose from any number of state-approved procedures -- a hysterectomy, breast reduction and chest reconstruction, for example - the only surgeries that Oregon initially agreed to cover for transgender women was so-called "bottom surgeries" to reconstruct their genitals. Breast augmentation was not covered.

Estrogen treatments for transgender women do spur some development of breasts, but it doesn't happen all the time. That's where surgery sometimes comes in. Washington, California, Washington, D.C., and Maryland all cover breast augmentation for transgender women. Until recently, Oregon did not.

It took 10 months for Oregon to approve the benefits -- state officials were not convinced breast augmentation was not just for looks. The issue came to prominence last October, when Legacy Health gynecologist Megan Bird told the Oregon Health Evidence Review Commission that Oregon should follow the lead of other states. Bird was among eight Legacy Health physicians who urged the commission to create a more equitable policy.

"I fundamentally believe that chest reconstruction is a basic part of trans health care," she said. "My patients consistently get into a Catch-22 with this issue. They can't get surgery because it is 'cosmetic,' but they don't fully pass as women without it. It becomes a safety issue for some women."

Commission members pushed back. Breast augmentation, they said, is cosmetic.

Other women have small breasts, Willamette Valley Health Authority Medical Director Holly Jo Hodges argued. The Oregon Health Plan didn't pay for those women to have implants.

Eventually, the commission agreed to include the coverage for select patients, though Hodges and other board members voted against it.

"There's this perception that when you are transgender, it's all about the genitals," Louise van der Eijk, an Ontario-based therapist who works with transgender clients in Eastern Oregon, said in an interview. "It's not. For my patients, it's about the voice. It's about the face. It's about the Adam's apple, the neck."

Heartened by that win, transgender women have petitioned the state to add facial feminization surgeries. Washington pays for some of those procedures, as well as Adam's apple shaving.

Sophia Stanford moved to Oregon from North Carolina last year in part to access the new Medicaid benefits. People harassed her in the South, she said, and her physician would prescribe only a very low dose of estrogen.

"I feel safe here," she said. "A friend told me health care was provided here. And this is the biggest trans girls population in the country."

The 37-year-old has struggled to find a job. She earned master's degrees in space flight and aeronautics from Embry-Riddle Aeronautical University and hoped to work as a test pilot. But potential employers see her as a liability, Stanford said.

She never makes it past the interview.

"My face doesn't pass," she said. "People look at me and say, 'That's a trans girl.' A lot of times, we won't get hired because employers don't want to deal with the social backlash of a trans women getting harassed at their company."

More than 80 percent of transgender Oregonians have been discriminated against or harassed at work, a 2011 survey revealed. Nearly 50 percent said employers did not hire them, and a quarter said they were denied promotions.

Stanford said expanding Oregon Health Plan coverage to include facial feminization surgery to soften her brow, jaw and nose would help.

"If I could get that, I could get a job and get off OHP," she said last year. "People say, 'You don't have to pass. Society should get better.' But most trans women I know want to pass just for the sake of safety and just to be able to make it through life."

Portland resident Rebekah Brewis said she, too, believed a facial surgery would help her find more stable employment. Brewis said she had trouble leaving the house some days because her nose is too masculine.

"I worry people see me as a guy instead of a woman," the 35-year-old said. "You can hide publicly what you have down there, but you can't conceal your looks."

She visited three Portland doctors, all of whom specialize in transgender care.

They tried to help, Brewis said, but ultimately her Medicaid organization denied the requests.

"Not being able to have that as an option feels pretty hopeless," she said.

In early March, Stanford grew tired of waiting. Friends chipped in money, and she flew to Florida for a $19,000 facial surgery. The swelling is still subsiding, but Stanford said she has already noticed a difference.

"I haven't been misgendered once since the surgery," she said. "I can actually go out in public, and I don't get harassed."

-- Casey Parks

503-221-8271

cparks@oregonian.com; @caseyparks