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, 47, 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.”

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 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.

But he also had a growing list of patients who said they were interested in vaginoplasties.

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.

What if, instead of going elsewhere, patients could get into their car and drive down the road to their hospital?

The opposition

Stiller’s request soon became a community-wide battle.

It began when another doctor at Pullman Regional Hospital, Rod Story, wrote an email to contest the possibility of vaginoplasties at their workplace.

“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.

When he first heard of Stiller’s plans for the surgery, he didn’t immediately send the email.

So 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.

He asked the pastor of his church if he should say something.

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

Public input

Story’s note spread around the hospital, but only two people responded. He was then called into a meeting with the chief hospital executive and chief medical officer, and they spoke for more than an hour.

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.

The final decision

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.

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.

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.

So when it came time to perform his first vaginoplasty on a 33-year-old woman named Sarah Bergman, Stiller chose to do it at Gritman Medical Center, 10 miles from Pullman, right across the Idaho border. At that hospital, administrators didn’t consider the public reaction. They seemed willing to open their doors for the surgery.

The same day of Bergman’s surgery, Story would meet with a real estate agent to scout nearby office space for a solo private practice. He wanted a place where he could comfortably take care of his patients.

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