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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.

The moon rises over homes near the University of Idaho in Moscow, Idaho. (Melina Mara/The Washington Post)
The moon rises over homes near the University of Idaho in Moscow, Idaho. (Melina Mara/The Washington Post)

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?

Rod Story has worked for eight years as a physician at Pullman Regional Hospital in Pullman, Wash. He respected his colleague, but Stiller’s request to perform vaginoplasties didn’t sit right with the reformed evangelical Christian. (Melina Mara/The Washington Post)
Rod Story has worked for eight years as a physician at Pullman Regional Hospital in Pullman, Wash. He respected his colleague, but Stiller’s request to perform vaginoplasties didn’t sit right with the reformed evangelical Christian. (Melina Mara/The Washington Post)

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.

©THE NATIONAL TIMES NEWS