But in order to really feel like herself, she needed to change her appearance. While living as a man, Hoskins had a beard so thick that it was impossible to shave every day. She feared that even if she started dressing and introducing herself as a woman, people would see her as a “man in a dress.” She wanted to like who she saw when she looked in the mirror. It wasn’t just her body hair, the clothing she wore, or her sexual organs that Hoskins was concerned about; it was the bone structure of her face. Hormones helped to redistribute the fat in her face to make it look more feminine, but she knew that the bones in her face had already developed and that it was “rough and masculine.”
Hoskins’s next step in transition is to undergo facial feminization surgery, a procedure she says she's wanted since before coming out. Although the surgery is well known within the transgender community, it is not yet widely available. But that’s changing, and Colorado will be at the forefront of the surgery's newfound popularity.
The LGBT Center of Excellence at Denver Health, which opened in 2017, will begin to offer facial feminization surgery this summer, making Denver Health one of only three public hospitals in the nation to offer it, according to Trans Health Care's surgeon directory. "Denver Health’s mission is Level One Care for All, and the organization realized we could do better to serve the LGBTQ population of Denver. We believe that no matter who you are that we are here to provide care through a person’s life span," Kari Kuka, the center's administrative director, wrote in an email.
According to Kuka, Denver Health has long provided the LGBTQ community with services such as HIV prevention and care, but patients wanted local access to gender confirmation surgeries, for which patients frequently have to travel to other states.
Facial feminization surgery is a combination of various plastic surgeries, usually performed at the same time, meant to soften and feminize masculine bone structure. In the procedure, the brow line is lifted, the forehead is made shorter, the Adam's apple is reduced, the nose is made smaller. According to Sable Schultz, transgender program manager at the GLBT Community Center of Colorado, a majority of transgender women now consider facial feminization surgery as a step in their transition.
As part of its new transgender program, Denver Health will also offer chest reconstruction, hysterectomies, orchiectomies and vaginoplasty. It will be the only hospital in the state and one of very few “safety net hospitals” in the country to offer comprehensive care with the needs of transgender patients specifically in mind, according to Kuka. Already, there is a two-year wait list for vaginoplasty, and fifteen patients have expressed interest in facial feminization, which involves extensive consultations before the procedure can take place. (Denver Health's Dr. David Khechoyan, who specializes in cranial facial plastic surgery for trauma patients, will begin consulting with patients next month.)
Though availability is expanding, transgender surgeries are still extremely expensive. According to the World Professional Association for Transgender Health, facial feminization surgery is particularly inaccessible because almost all insurance companies deem it a cosmetic procedure and refuse to cover it. Depending on what needs to be done, it can cost upwards of $35,000 to $50,000, according to Kuka. “This is a surgery that is really out of reach for the majority of the population,” Kuka says.
Hoskins expects an uphill battle with her insurance company before she can determine whether she'll be able to undergo facial feminization procedures at Denver Health. She plans to argue that the surgery is not cosmetic but medically necessary in order to address gender dysphoria, the deep anxiety transgender that people feel when they aren't recognized as the gender with which they identify.
"[Cisgender people] don't understand how deep it goes and the problems it can cause when you wake up every morning and you feel like you look like a gender other than what you are," says Hoskins. "It has really deep psychological repercussions that, especially over the course of time, can really wreak havoc on your mental health. It's much different from just saying, 'Oh, I wish my nose was a little bit thinner.'"