PULLMAN, Washington — The surgeon had spent several years preparing — reading medical journals, finding someone to train him, practicing on cadavers — until only one hurdle remained: getting permission for the medical procedure he wanted to bring to this small community on the Washington-Idaho border.
“Vaginoplasties,” Geoff Stiller remembered telling the CEO of Pullman Regional Hospital, referring to the surgical construction of vaginas for transgender women. “I want to do them at your hospital.”
Nine months later, Stiller looks back on that conversation as a final moment when his request still seemed like an easy one. Nobody yet had cited Bible verses or argued that culture was blurring the line between men and women. Another doctor at Pullman hadn’t yet sent an email to eight co-workers, who forwarded it around the hospital, with the subject line “Opposition to Transgender Surgery at PRH.” The hospital hadn’t yet received hundreds of letters from the community. Stiller hadn’t yet lost 20 pounds from the stress, nor had he yet anticipated that his request might turn for him into something more — a fight not just over a surgery, but over what he’d later call a “moral issue.”
The only thing Stiller was trying to do on that initial day was expand his career in a direction he had come to see as fascinating and much-needed. There were several dozen American doctors performing vaginoplasties — almost all of them, until that point, in major cities.
But Stiller, 47, was different from those other doctors because he worked in a rural area with 60,000 people — side-by-side college towns surrounded by conservative farming counties. He had spent much of his career in places like this, performing appendectomies, responding to middle-of-the-night emergencies, pulling up to the hospital in his pickup truck.
Yet it was precisely because of where he worked that Stiller felt certain he was witnessing a widening social — and medical — movement. Even here, a stream of transgender patients was coming into his waiting room, asking for help. One patient was in her 60s, balding and graying, saying she had just recently decided to transition to female. Another patient was rolling up her sleeves, showing Stiller the self-inflicted cuts on her arm. Another was walking in for the first time, kneading her fingers, as Stiller introduced himself and then said, “So, tell me your story.”
“Well, I’ve been living full time as myself for about 2½ years,” she said.
“Family? Are they okay with this?” Stiller asked.
“Not supportive. I haven’t talked to them in two years.”
“I am sorry,” Stiller said, and then he asked her how he could help.
Sometimes, the patients wanted breast augmentations. Other times, breast removal or facial feminization. Stiller had offered those procedures for several years. But he also had a growing list of patients who said they were interested in vaginoplasties.
That surgery was the final and most significant step of a female transition — and over the past few years, insurance programs had started to cover its cost. Stiller could pinpoint only one reason the procedure wasn’t more commonplace: a lack of training programs. But the videos he watched showed a surgery that maintained the nerves of the male genitals to build working, sensation-feeling female genitals. The transgender medical books he bought, citing study after study, called the surgery “the best way” to help people with severe dysphoria.
“The right thing to do,” Stiller found himself saying.
Before Stiller spoke with the hospital CEO, patients in the region who had wanted the surgery had one option: to go elsewhere. They could fly to Thailand or India, paying in cash. They could put their names on lengthy waiting lists for surgeons in Chicago or San Francisco. As far as Stiller knew, no other surgeon in Montana, Idaho or Washington state was offering the surgery — something he told the CEO at Pullman Regional. He believed there was no reason those people needed to go so far. What if, instead of going to Thailand, patients could get into their car and drive down the road to their hospital?
The first inkling that this wasn’t going to go easily came three months after he brought up the idea with the CEO, in the form of an email from another doctor. “I am writing to you seeking to develop a response to plans by Dr. Stiller,” an email from Rod Story began, and his letter was now in the hands of almost every employee at Pullman Regional.
“I do not find convincing data . . . ” he had written.
“Contrary to good medical care . . . ”
“Drastic and irreversible . . . ”
And then: “If you would like to join my efforts in opposing this surgical technique, please feel free to contact me.”
Like Stiller, Story was a doctor of good reputation in the community. Unlike him, he saw the surgery not as the right thing to do, but as something that defied his most basic belief as a physician and a reformed evangelical Christian: that there are immutable differences between men and women.
Story, 43, had been conflicted about whether to share his views widely. He respected Stiller and considered him highly skilled. Plus, Story liked his job. He had been a physician at Pullman Regional for eight years, treating nonsurgical patients and assisting surgeons before and after their procedures. He and his wife had nine children, a spacious and renovated house on a hill, a back yard with a picnic table that overlooked miles of wheat and lentil fields and buttes. “Our ride-into-the-sunset plan,” Story’s wife, Jenny, called it.
But Story also felt that he had built much of his life by following his conscience, even when it was inconvenient. Two decades earlier, Jenny had gotten pregnant. They weren’t yet married. Story was a pre-med student. They had no money for a baby. They were embarrassed at having crossed a moral line, and they talked about crossing one more line — getting an abortion. Instead, Story temporarily dropped out of school. Jenny delivered the baby. Story spent three years working as a janitor, earning money, and feeling he had preserved some part of what he believed in.
When he first heard of Stiller’s plans for the surgery, he didn’t immediately send the email.
First, he did some research. He Googled terms like “transgender surgery risk,” collecting 40 transgender-related links on his computer, and what he concluded was that Stiller was right to be concerned about the patients and wrong to offer them surgery. These were patients with mental conditions, Story felt. “It’s a body dysmorphic disorder,” he said of the conclusion he had reached. “You have an incorrect perception of your body. Probably the most common example is anorexia.” It was a hospital’s job to protect those patients, not enable their wishes. That was enough to concern him, but making it worse, he said, was that the hospital couldn’t guarantee he would be excused from preparing the patients for operations.
“I need some advice,” Story remembers telling Doug Wilson, a pastor who founded Story’s church. Wilson said it felt like a “secularist, nonbelieving morality is being jammed down our throats.”