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."
"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."
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."
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.