A moral di­vide over a surgery

Con­ser­va­tive com­mu­nity split on hos­pi­tal of­fer­ing trans­gen­der pro­ce­dure

The Washington Post Sunday - - FRONT PAGE - BY CHICO HAR­LAN IN 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 21/2 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.”

“What is a man? What is a wo­man?” Wil­son said. “The shared con­sen­sus is al­most gone. This is a fun­da­men­tal is­sue.”

Story sent the email and waited a day as his note spread around the hos­pi­tal. Then, his phone rang. He was called into a meet­ing with the hos­pi­tal chief ex­ec­u­tive, Scott Adams, and the chief med­i­cal of­fi­cer, Ger­ald Early. They talked for more than an hour, ac­cord­ing to notes Story kept, and by the end, Adams won­dered if the hos­pi­tal had been mov­ing too fast. He called Story’s ob­jec­tions “the tip­ping point.”

What hap­pened af­ter that was an an­nounce­ment: Even as Stiller per­formed two train­ing vagino­plas­ties — su­per­vised by a more ex­pe­ri­enced sur­geon from Los An­ge­les — Pull­man Re­gional said it would ask for pub­lic in­put, ac­cept­ing com­ments from res­i­dents for three weeks. The ini­tial hos­pi­tal an­nounce­ment was just a short news re­lease with an email ad­dress, but soon the an­nounce­ment was posted all over Face­book, and that was all it took to open a split in the com­mu­nity.

“This surgery will save lives,” one res­i­dent wrote.

“Cut­ting off/out sex­ual or­gans doesn’t change our chro­mo­somes,” said an­other.

“A hos­pi­tal should be a place of heal­ing and rest, and not a place of tur­moil and cul­tural con­flict.”

“Of­fer the damn surgery and tell ev­ery­one else to mind their own busi­ness.”

The hos­pi­tal re­ceived hun­dreds of com­ments, as well as thou­sands of sig­na­tures in du­el­ing pe­ti­tions started by Wil­son’s church and a uni­ver­sity as­so­ci­ate dean. The hos­pi­tal heard from ac­tivists, from for­mer pa­tients, from the Amer­i­can Civil Lib­er­ties Union, from em­ploy­ees in sup­port, from em­ploy­ees in op­po­si­tion.

All through this, Stiller stayed si­lent. “The high road,” he called it, but he was also hid­ing his anger. He stayed away from the In­ter­net. He skipped meals. He spent a week­end camp­ing with his par­ents — “Trump sup­port­ers to a T,” he called them — and couldn’t bring him­self to tell them he was push­ing for these surg­eries. “We’re step­ping back on so­cial is­sues,” he re­mem­bered think­ing to him­self.

Stiller fig­ured he would be able to per­form the vagino­plas­ties some­where. He had asked per­mis­sion from an­other small hos­pi­tal as well — Grit­man Med­i­cal Cen­ter, 10 miles from Pull­man, right across the Idaho bor­der. At that hos­pi­tal, the ad­min­is­tra­tors didn’t con­sider the pub­lic re­ac­tion. They seemed will­ing to open their doors for the surgery. So, maybe Stiller wouldn’t need Pull­man Re­gional af­ter all. But the longer the de­bate went on, he re­al­ized that wasn’t the only point. He thought ev­ery hos­pi­tal, pre­sented with a choice, should reach the same de­ci­sion. “We need to be­come com­fort­able tak­ing care of these pa­tients,” Stiller said.

Story, mean­time, posted his views on so­cial me­dia, then one Sun­day walked into his church and found out that the ser­mon was about him. “Think of Rod and Jenny Story right now,” the pas­tor, Ty Knight, told the con­gre­ga­tion, and Story could feel some eyes turn to­ward him and his wife.

Story had some­times felt alone since writ­ing the let­ter. His ini­tial email had been read by al­most ev­ery­body at Pull­man Re­gional, posted at nurse’s sta­tions, and only two peo­ple had re­sponded to him. But that was the med­i­cal com­mu­nity, and this was the church, and there were 120 peo­ple in the pews, and a

thou­sand other mem­bers of af­fil­i­ated con­gre­ga­tions in the area, and it was here at least where Story sensed sup­port.

“There is a great sin that is look­ing to come into the [re­gion] of hav­ing trans­gen­der surgery,” the pas­tor said. “Rod is faith­fully holding to God’s word.”

As the hos­pi­tal de­bated what to do, Stiller was com­pil­ing a list of pa­tients who wanted the surgery, and this was the name right near the top: Sarah Bergman, 33, who lived two miles from Pull­man Re­gional. “The last step,” Bergman called it. For so long, the de­sire for the surgery had been Bergman’s per­sonal se­cret — some­thing dis­cov­ered on the In­ter­net by a pre­teen. The cer­tainty of be­ing fe­male went back as far as Bergman could re­mem­ber, to be­ing 2 or 3 years old and start­ing to wear dresses. At 6, fam­ily mem­bers were say­ing the be­hav­ior had to stop. At 12, be­gin­ning to grow some fa­cial hair, Bergman re­fused to go to school, mak­ing up ex­cuses for two years, fi­nally be­com­ing an eighth-grade dropout in the Ari­zona sub­urbs who felt com­fort­able al­most nowhere, ex­cept alone in the bed­room.

The on­line world was Bergman’s only one for al­most the next decade. Eat­ing be­came com­pul­sive. So did play­ing video games — with an avatar called Sarah. The fear of be­ing dis­owned was con­sum­ing. Bergman fi­nally said it as force­fully as pos­si­ble at 23, weigh­ing 360 pounds, with a dark beard, while go­ing through a Wendy’s drive-through with a grand­par­ent: She was a wo­man.

“I was just so des­per­ate,” she said. “Af­ter that, I started ex­ist­ing in the real world.”

First, she just started buy­ing a few pieces of women’s cloth­ing. But then she found a ther­a­pist. She started us­ing a tread­mill. She lost weight. She started tak­ing es­tro­gen. She had her fa­cial hair re­moved. Peo­ple started as­sum­ing she was a wo­man. On a trans­gen­der on­line fo­rum, Bergman struck up a friend­ship with an artist, and then trav­eled to Pull­man to meet her. Within four years they would be mar­ried, and Bergman en­rolled at Wash­ing­ton State Uni­ver­sity, ma­jor­ing in molec­u­lar bi­ol­ogy, al­most a decade older than her class­mates.

She con­sid­ered Pull­man a “nice small town,” a place where she earned money pulling night shifts as a cam­pus pub­lic safety of­fi­cer and could feel safe walk­ing back to her apart­ment at 2 a.m. For the first time, she said, it barely mat­tered that she was trans­gen­der.

But then came the Pull­man Re­gional an­nounce­ment and all the com­ments — not just sub­mit­ted to the hos­pi­tal but all over Face­book. Bergman’s wife, who is also trans­gen­der, wor­ried about their safety. Maybe the same peo­ple call­ing trans­gen­der peo­ple “de­viants” on so­cial me­dia were stand­ing next to them at the su­per­mar­ket check­out. Maybe their neigh­bors were the ones read­ing Story’s in­ter­view with the col­lege pa­per, where he said the vagino­plas­ties of­fered “false hope.” One day, Bergman’s wife opened her lap­top and com­posed a let­ter. “Dear Dr. Story,” it be­gan, and she de­scribed the “harm” he had done “un­der the guise of Chris­tian­ity.”

“I have lived in the Pull­man re­gion for about 6 years now,” she wrote, “and un­til this episode I felt at peace for prob­a­bly the first time in my life. Your be­hav­ior has turned that peace up­side down.”

Bergman read the let­ter and said it was pow­er­ful. But she also thought that not ev­ery­body needed to agree to open the door to progress. The surgery was a per­sonal de­ci­sion, be­tween a doc­tor and a pa­tient. And in her own case, it had come eas­ily. She had stud­ied how the surgery worked. She had re­searched the cri­te­ria for pa­tients: a re­quired year-long pe­riod of us­ing hor­mones and liv­ing as a wo­man and let­ters of re­fer­ral from men­tal health ex­perts. She had also looked into the risks. Some pa­tients’ new gen­i­tals didn’t func­tion. Bergman felt she could han­dle any of it.

The only part she hadn’t en­vi­sioned was that a sur­geon in her own town would be­come in­ter­ested in the vagino­plas­ties. It was a sur­geon she knew and liked — one who had per­formed three other cos­metic pro­ce­dures for her. Bergman had been think­ing about head­ing to a clinic out­side Philadel­phia for the surgery. In­stead, she de­cided to wait on Stiller. They had two con­sul­ta­tions over the sum­mer, and then Bergman was ready.

“If ev­ery hos­pi­tal of­fered this, it wouldn’t be such a big deal,” Bergman said.

“Even­tu­ally,” her wife said, “I think ev­ery­body will be do­ing it.”

“Even­tu­ally.”

Seven months af­ter Stiller’s con­ver­sa­tion with the CEO, af­ter all the pub­lic com­ments, af­ter all the sig­na­tures and pe­ti­tions, Pull­man Re­gional Hos­pi­tal had a board meet­ing where it would an­nounce a fi­nal de­ci­sion. Peo­ple filed into a con­fer­ence room, in­clud­ing Story, and sit­ting up front were the hos­pi­tal board mem­bers.

Ad­min­is­tra­tors had pre­pared a re­port, passed out to the au­di­ence, say­ing that the last months had been “po­lar­iz­ing” but that sup­port­ers for the surgery well out­num­bered the op­po­nents. It said “gen­der re­as­sign­ment surgery is a grow­ing med­i­cal prac­tice.” Then the seven-mem­ber board voted unan­i­mously to give Stiller the green light.

Story slipped out of the meet­ing be­fore it ended, and min­utes later he was back in­side his home on the hill, back in front of his com­puter, and this time he pulled up a doc­u­ment he had already started work­ing on — one he wasn’t sure un­til now that he would need. He tweaked a few words and looked it over. “I am re­gret­fully re­sign­ing from my po­si­tion,” it said, and then he thanked the hos­pi­tal for eight years of em­ploy­ment. He said his last day would be Dec. 31, 2017.

Over the next weeks, he thought about what to do next. His wife wor­ried that new po­ten­tial em­ploy­ers would Google his name and con­clude he was “Dr. Bigot.” Maybe he could reach out to old med­i­cal friends to land a dif­fer­ent job in town.

“Haven’t got­ten many call­backs,” Story said one evening.

“You haven’t got­ten a sin­gle call­back,” Jenny said.

“Our cul­ture is mov­ing out of lock­step with us a bit,” Story said.

“A bit?” Jenny said. “It’s a whole dif­fer­ent di­rec­tion. We’re not even on the same road any­more.”

For Stiller, the ap­proval from Pull­man Re­gional had been months in the mak­ing, but he felt lit­tle bet­ter than if the hos­pi­tal had said no. Open­ing the de­bate to the pub­lic had been so bruis­ing, he felt.

Only days ear­lier, Grit­man Med­i­cal Cen­ter had also given him the fi­nal clear­ance; the hos­pi­tal’s CEO said she con­sid­ered the vagino­plas­ties “no dif­fer­ent from any other service line we would pro­vide to the com­mu­nity.” It was that hos­pi­tal, not Pull­man Re­gional, that was re­ally ready to treat trans­gen­der pa­tients, Stiller felt, and so that’s where Bergman ar­rived be­fore sun­rise on a cool au­tumn Fri­day, the same day Story would meet with a real es­tate agent to scout nearby of­fice space for a solo pri­vate prac­tice.

Bergman walked up to the sec­ond floor of the hos­pi­tal, changed into slip­pers, changed into a gown, and then there was a knock on her wait­ing room door.

“Good morn­ing,” Stiller said, walk­ing in.

He crouched at the foot of Bergman’s bed, so he was eye-level.

“What ques­tions do you have?” he asked her.

“How long will it take, do you think?” she asked, and he said five or six hours.

He smiled. “We can rush it and do it in one if you want.”

“I already went through all the freak­ing out,” Bergman said.

“Okay, sign the con­sent form and we’ ll get started.” “Okay.” The op­er­a­tion took all morn­ing, and when it was over, Bergman was wheeled into a re­cov­ery room, where soon she would wake up, the anes­the­sia wear­ing off, with ban­dages packed around her gen­i­tals and a sur­gi­cal tech­ni­cian say­ing, “Ev­ery­thing went great, sweetie.”

Down the hall­way, hos­pi­tal staff cleaned and ster­il­ized the sur­gi­cal in­stru­ments, while Stiller wiped off a lit­tle sweat. He took a 45-minute break. He called Bergman’s wife. He ate a sand­wich. Then he walked back to­ward the oper­at­ing rooms, be­cause soon he had to get back to work. He had a sec­ond vagino­plasty sched­uled for the af­ter­noon, and then the fol­low­ing morn­ing a third.

PHO­TOS BY MELINA MARA/THE WASH­ING­TON POST

TOP: Ge­off Stiller vis­its pa­tient Sarah Bergman. ABOVE: Rod Story op­poses the sur­gi­cal tech­nique.

PHO­TOS BY MELINA MARA/THE WASH­ING­TON POST

TOP: Rod Story puts away laun­dry with the help of daugh­ter Lucy, 7, in Moscow, Idaho. Story re­signed from his hos­pi­tal post in protest over vagino­plasty surg­eries.

ABOVE: The moon rises over homes near the Uni­ver­sity of Idaho in Moscow, which is near the Wash­ing­ton state bor­der.

RIGHT: Story speaks with a pa­tient at Pull­man Re­gional Hos­pi­tal in Pull­man, Wash. His email to the hos­pi­tal CEO op­pos­ing vagino­plas­ties was viewed as a “tip­ping point.”

PHO­TOS BY MELINA MARA/THE WASH­ING­TON POST

TOP: Ge­off Stiller per­forms a dou­ble mas­tec­tomy as part of a sex re­as­sign­ment at Grit­man Med­i­cal Cen­ter in Moscow, Idaho.

MID­DLE: Stiller, who per­formed a vagino­plasty on Sarah Bergman, vis­its her at Grit­man. Days be­fore Pull­man Re­gional Hos­pi­tal ap­proved vagino­plas­ties, Grit­man gave the go-ahead for the pro­ce­dure. Many trans­gen­der peo­ple travel to other coun­tries for the pro­ce­dure.

ABOVE: Stiller at his prac­tice.

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