Guilderland

Gio Mariah was adamant about the photograph.

It's glamorous. She is lying on her side in grass of fluorescent yellow and green shades, her skin glistens in the sun, her red hair glows.

When she asked the Times Union to consider writing a profile about her, Mariah insisted that be the featured portrait.

"I want this to be authentic to myself and my journey and how I represent as a female," she wrote.

Mariah eventually agreed to the paper's use of its own more realistic photographs, in keeping with journalistic protocol. Her concern over her image is nonetheless telling in light of her journey, which has much to do with how she is perceived.

What the 23-year-old wants is to shout out that she is a successful woman who is comfortable in her own skin. Having overcome hurdles in her transition from a man, she sees herself as a role model for transgender people working to conform their internal sense of gender to their appearance.

What she doesn't want is to harp on her struggle to get here. In fact, the greatest adversity in her young life had nothing to do with gender or sexuality, but with the loss of her beloved sister, Jacquelyn Porreca. A 32-year-old barber, Porreca was senselessly killed two years ago by a man seeking to rob her Colonie salon for money to buy heroin.

Yet it would be a lie to suggest that Mariah's path to womanhood was smooth. Even as celebrities like Caitlin Jenner and Laverne Cox have brought increased visibility to male-to-female transitions, and state regulations have ensured transgender patients' right to treatment and insurance coverage, Mariah's transformation required tenacity.

"Besides what happened with Jackie, health insurance was my one big heartbreak," Mariah said.

Mariah did not always identify as a woman. At Guilderland High School, she came out as an androgynous male, living as a gay man but expressively feminine. She suggested David Bowie or Boy George as an analogy to her high school persona. But her feminine characteristics went beyond the way she dressed. She recalled, for instance, getting moody at the same time each month that Porreca and her two other sisters had premenstrual syndrome.

Porreca, 11 years older, was Mariah's biggest fan, the person whose love was unconditional. Mariah describes her late sister as her perfect complement: "We were mirror images of each other." It was Porreca who supported Mariah in becoming an aesthetician, helping to pay for her training. She urged Mariah to strike out on her own after a fire in 2014 destroyed a building where they had shared space. Mariah opened Gio Expressions Private Spa, off Western Avenue.

Porreca encouraged Mariah to embrace her authentic self. She would gently nudge her sibling, "Gio, if you're happy, do whatever you want." Sometimes she'd be more direct: "Do you want to be a girl?"

Porreca was supportive in early 2015 when Mariah started therapy for gender dysphoria, a disorder marked by distress that results when a person does not identify with the gender assigned at birth.

There is no one right way to remedy this dissonance, experts said. For those who transition from one gender to another, the change can take many forms, said Lyndon Cudlitz of Albany, who trains organizations on LGBTQ issues. Some people want talk therapy only. Others seek hormone treatments, with or without gender reassignment surgery. Some want certain procedures — breast augmentation or genital reconstruction or facial feminization — but care less about others.

The goal in whatever treatment is chosen is to address the anxiety and depression that are the hallmark of gender dysphoria, said Acey Mercer, a psychotherapist at Choices Counseling and Consulting in Albany.

For Mariah, the aim was to look and feel "female and pretty," she said. But just months into therapy, she hit a psychological block that few people could even imagine.

"My sister was murdered, and that destroyed my life," she said.

There are details of Porreca's final hours in August 2015 and the months that followed that are burned into Mariah's memory in the vivid way only trauma can forge: The cryptic "911" text message she got from a client of Porreca's who saw the barber walk out of her salon after being stabbed. Standing at Porreca's bedside, when Mariah believes her sister relayed that she knew her assailant. The terror she and the rest of the family felt afterward, as police kept a lookout on the salon. Her disgust at the narrative that developed around the murderer's heroin addiction, as if that made his murder of her sister less evil.

Mariah lived afterward with the hypervigilance of post-traumatic stress, and her anxiety contributed to her breakup with her boyfriend of three years, she said.

It took a year after Porreca's death for Mariah to start hormone therapy to feminize her appearance — to give her breast tissue, and change her hairline and the distribution of fat and muscle, among other things. Before beginning treatment, genetic tests confirmed what she had to some degree intuited: Her testosterone levels were low for a male, her estrogen levels closer to the average female's. There was also something unusual about her chromosomes. Though men have XY chromosomes, Mariah also had XX chromosomes, like a woman. Doctors told her she was "intersex."

The hormone treatments effected some concrete changes that made Mariah less muscular and sizable. Her breasts developed to a B cup and she lost a couple of inches in height, she said. Her senses, especially hearing and taste, were heightened.

It was not enough for Mariah. She looked and sounded like a trans woman. But she felt like a woman, period. That's how she wanted others to see and hear her. So she underwent voice modification therapy at the College of Saint Rose in Albany and sought surgery to make her appearance more feminine.

Perhaps surprisingly, given how open Mariah is about most actions she had taken in her transition, she will not answer the question she is most frequently asked: Has she had genital reconstruction surgery? She is silent on it, she said, because people are too quick to associate genitals with gender. Her reproductive organs are irrelevant to who she is, she said.

Yet while she believes the most private aspects of her physique to be insignificant, it was of utmost importance to Mariah that her outward appearance be feminine. While somewhat smaller and softer after hormones, she still had the face of a man. Her hairline was farther back than a woman's, her brow bone too strong, her nose, chin and jaw too big.

More Information Facial feminization Without being conscious of it, we identify some facial features with men, others with women. Here are features that may be changed as part of facial feminization surgery, according to Dr. Sherman Leis, a plastic surgeon outside Philadelphia who performed surgery on Gio Mariah. Forehead: Men's are bigger. Women's are smaller and flatter. Men's hairlines are lower in the middle and elevate to a bald area around the temples. Browbones are more prominent in men. Plastic surgeons can move hairlines to lessen the forehead area and elevate the brows while reducing the browbone. Nose: Women's are smaller, narrower and with a higher tip. Lip: Women's tend to be fuller. The distance between the nose and the lip is larger in men. Men's upper lips are thinner. Chin: Men's chins are generally more square, women's are narrower. Jaw: Women's jaws are generally more narrow toward the chin. Shape: Women's faces are usually more triangular. Cheek implants can achieve this effect. Adam's apple: Thyroid cartilage is often prominent in men. Source: Dr. Sherman Leis, The Philadelphia Center for Transgender Surgery The cost of gender reassignment Here's what Dr. Sherman Leis charges for some male-to-female surgeries. Prices include anesthesia and hospitalization. Genital reconstruction$19,750 Breast augmentation$8,200 Forehead/brow lift with browbone reduction$6,200 and hairline advance Rhinoplasty (nose job)$7,500 Adam's apple reduction$3,600 Source: Dr. Sherman Leis, The Philadelphia Center for Transgender Surgery See More Collapse

So she sought surgery to feminize her face. It was at this point that Mariah ran into problems with insurance, with an apparent conflict over what is medically necessary versus cosmetic.

To Mariah, there was no question: She needed facial feminization surgery, first, to relieve her dysphoria by allowing her to look like the woman she is, and second, as a matter of safety. Transgender people are often targets of violent crime.

"If my face doesn't match my gender, that puts me at risk," Mariah said.

Local experts in transgender care agreed with her assessment, at least for some people.

"Presenting as the gender that you identify with is a really big issue," said Emma Corbett, a spokeswoman for Planned Parenthood Mohawk Hudson, which provides medical services to transgender patients. "When we see so many instances of trans phobia and trans crime in the media, it's really easy to see how passing helps."

Mariah's health insurer, CDPHP, however, would not initially cover surgery to change her face. A spokeswoman for the Albany-based company, Ali Skinner, would not comment on Mariah's case, citing privacy rules. But she said there is a formal process for getting such major surgeries authorized, and customers can become frustrated if they don't follow it precisely.

In general, gender reassignment surgeries are being performed more often and are covered more often than ever, experts said. Transgender-related surgery rose 20 percent from 2015 to 2016, according to a May report from the American Society of Plastic Surgeons. State regulations required Medicaid to cover surgeries as well as hormone therapy for gender dysphoria in adults in 2014, and then for minors two years later. Private insurance companies were also put on notice in 2014 that they could not deny medically necessary treatment to New Yorkers with gender dysphoria.

Genital reconstruction surgery is now mostly covered, said Cudlitz, the LGBTQ educator, and while trans patients had to fight for coverage for breast augmentation in the recent past, that is more commonly covered now, too. But trans people looking to get facial feminization surgery should be prepared to receive a coverage denial notice, he said.

"We shouldn't be doing that," Cudlitz said. "You shouldn't have to go through that (appeals) process and have to have the stamina and resources to fight it."

A spokeswoman for the state's health insurer trade group, Leslie Moran, said that unlike other gender reassignment surgeries, facial feminization falls into a gray area. It's clear, for instance, that removing an Adam's apple from a trans woman is necessary, she said, but less so is moving a hairline or re-shaping a brow bone.

"You could make that argument for a non-trans woman who says, 'I have this really prominent nose, or I inherited my dad's really strong chin, and I want to look more feminine,'" said Moran, of the New York Health Plan Association. "But it falls under that cosmetic classification."

Trans patients who believe their insurance companies have wrongly classified a procedure as cosmetic have a right to appeal, Moran said.

That's what Mariah did. She got letters of support from nine professionals she had seen for care, including her primary care doctor, psychologist and endocrinologist, she said. CDPHP relented, and Mariah had the facial feminization surgery done in July by a plastic surgeon outside Philadelphia. (Most trans patients must travel to big cities for these procedures, Cudlitz said.)

The facial feminization has made all the difference in the world, according to Mariah.

"Everyone knew I was transgender, and people don't anymore," she said.

Now she's fighting for breast augmentation. While Cudlitz said that procedure is increasingly covered, Mariah said CDPHP denied her request because she has already developed breast tissue through hormone treatments. Her breasts are small in proportion to her body, however. Mariah has filed a complaint about the denied coverage with the state Health Department's Managed Care Unit.

Despite that pending matter, she does not talk about her transition as if it is incomplete. She defines herself as a woman, with no qualifying adjective. She has for all intents and purposes reached her destination.

Missing at the end of her journey, of course, is Porreca. Her presence remains in Mariah's daily life, however. Her name is itself a reminder: While she has always been Gio, once short for her given name Giovanni, she took Mariah, Porreca's middle name, during her transition. Mariah's long locks are also a tribute to Porreca, the last person to cut her hair.

Working to heal from that loss, she described her most fundamental rule about living as if it were simple.

"Why not be happy in life?" Mariah said. "That's what Jackie would want — for me to be happy."

chughes@timesunion.com • 518-454-5417 • @hughesclaire