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Dr. Toby Meltzer turned Scottsdale into a worldwide destination for gender reassignment surgery almost by stealth. His new partner and protégé may change that.
As a brilliant young surgeon, Dr. Toby Meltzer was capable of performing the most complex of plastic and microsurgery procedures: on hands, on nerves and blood vessels, on faces damaged by cancer or car accidents.

But those weren't the patients he coveted. He was a gender reassignment surgeon. And because of that fact, he couldn't find a place to operate in the entire state of Oregon.

Meltzer had already moved his growing practice away from one hospital in Portland, which at times had denied his patients a bed the day they arrived for surgery. The next hospital, initially accommodating, changed its tune when it hit financial trouble. Administrators told Meltzer they were unable to recruit physicians because of the stigma attached to his work. He wasn't welcome there - nor was he welcome anywhere, he learned as he toured the state requesting hospital privileges. The year was 2003.

Meltzer considered shifting his focus back to the traditional plastic surgery he'd trained for years to perform. But he kept thinking of his transgender patients, and about how few other surgeons in the country could help them become the people they felt they were supposed to be. "No one asks for this. It's not a choice they make," he says. "It was tempting [to give up] at that time... but I wasn't going to let my patients down."

The fact that Meltzer was driven out of one of America's most liberal states seems hard to imagine now that he's spent more than 13 years quietly practicing in Scottsdale without incident.

It's even harder to imagine now that TIME magazine has trumpeted "the transgender tipping point" on its cover. Now that Bruce is Caitlyn. Now that Meltzer, 58, has worked with more than 3,000 patients, inspiring demand for his services so great that he's expanding his practice to include another surgeon.

One who happens to understand transgender patients better than he even could.

Unexpected "Residency"
After performing his first gender reassignment surgery, Meltzer vowed never to do another.

"I have no idea what I'm doing," he remembers thinking. "I'm going to stick to the things I know."

Meltzer knew nothing about transgender health in 1990, when he began working for Oregon Health & Science University in Portland. Even now, no transgender surgery residencies or formal training programs exist in the United States. Doctors must learn the surgeries as Meltzer did: from surgeons willing to teach.

He was a year out of plastic surgery residency when two doctors at the Portland hospital approached him about taking over their practice. A plastic surgeon and a urologist had been teaming up for gender-reassignment surgeries, but with both retiring, they wanted someone to continue their work.

Meltzer, whose career goal had been to perform a wide variety of surgeries, accepted the challenge of learning. Because the two doctors performed gender reassignment surgery only a few times per year, Meltzer's "residency" consisted only of observing one surgery by each doctor. He also traveled to Colorado, where Dr. Stanley Biber started the first private gender reassignment practice in 1969, to watch one more. In Meltzer's early procedures, another doctor in Portland assisted him with urology, a specialty in which he was never formally trained.

But largely, Meltzer taught himself. In female-to-male surgery, the uterus and ovaries are removed before constructing what looks like a penis, either from a clitoris enlarged by hormone therapy or skin grafted from another part of the body. While the surgery has not been perfected, it can leave patients with the ability to stand to urinate and with sexual sensation from the clitoris. Reliable statistical studies are notoriously elusive, but several European studies do seem to indicate generally positive satisfaction rates among patients, despite significant post-surgical mechanical issues. (See sidebar.)

Male-to-female surgery involves removing the testicles and tissue from the penis, inverting skin to form a vagina and turning scrotum skin into labia. Meltzer pushed himself to improve the procedure, becoming the first in the U.S. to create a clitoris with sensation by rearranging nerves in the tip of the penis - offering patients real sexual function instead of what had essentially been an amputation.

It's 80 percent plastic surgery, Meltzer says, and 20 percent complicated urology. Genitals not only need to be reshaped, but they need to function - and surgery requires dangerous proximity to the bladder, urethra and rectum. "It's a challenge on almost everyone you do, and I've done over 3,000 of them," he says. "You're a millimeter or two from creating a disaster if you don't know what you're doing."

Meltzer's first procedure resulted in enough trial and error that the patient later required additional surgery. He was ready to dismiss the idea of more surgeries when the patient sent him a note, thanking him "for validating their life and helping them live the way they needed to live," Meltzer says.

That kind of gratitude is what inspired Meltzer - along with his wife, three children and even four members of his office staff - to continue the practice in Scottsdale. Meltzer insists that any cosmetic surgeon would prefer working with his patients over the typical cosmetic surgery patients.

"They're so much easier to deal with and so much nicer and so much more appreciative of what you do," he says. "I get thanked every day."

Best in the World
In another specialty, Meltzer might be the best-known doctor in town, the kind hospitals advertise on billboards and in magazine ads.

Meltzer is "without a doubt, the best in the world," says Dr. Burt Webb, a Scottsdale OB-GYN who assists him in female-to-male surgeries.

But Meltzer has never promoted his practice, and has rarely granted media interviews. For years, his office address wasn't listed on his minimalistic website. It's perhaps one reason controversy never followed him to Scottsdale, a city recommended to him by a former patient, a doctor. No one knows he's here.

"He just wants to take care of his people," Webb says. "That's all he really cares about."

Besides, the people who needed to find him always have, anyway.

In the early '90s, Meltzer unknowingly attracted out-of-state patients who mentioned a then-unfamiliar term: chat rooms. A former patient had shared surgery photos online at the time when the Internet was proliferating - and transgender people were discovering they weren't alone in feeling they were born into the wrong body. Meltzer's few gender reassignment surgeries per year turned into more than half his work by 1996, when he started a private practice.

Now, out-of-town or even out-of-country patients account for more than 85 percent of Meltzer's caseload,
and nearly all of the procedures Meltzer performs at Greenbaum Surgical Specialty Hospital in Old Town are transgender-related. Operating Monday through Thursday, with two 12-hour days, he does at least five male-to-female and two to four female-to-male procedures a week.

The term "sex change surgery" isn't preferred, nor is it very accurate. The "change" should be a transition to the desired gender over the course of a year or longer before surgery, according to care standards published by the World Professional Association for Transgender Health (WPATH). Another prerequisite: two referrals from mental health professionals.

The transition isn't a one-step procedure, either. A male-to-female patient, who typically has genital surgery in two stages, may simultaneously undergo breast augmentation, facial feminization and body sculpting procedures like a chondrolaryngoplasty, colloquially known as a shaved Adam's apple.

In a surgery prior to the main procedure performed by Meltzer, a female patient has her ovaries and uterus removed by Webb. (Female-to-male patients generally take testosterone supplements in perpetuity after their procedures.) He also performs a vaginectomy, removing tissue to support other organs, which leads to fewer complications in the next surgical stages. Webb is one of few surgeons worldwide performing the procedure for gender reassignment, thanks to Meltzer's unique vision.

"His brain works in an artistic fashion," Webb says. "A lot of people can paint, but there are only a few masters. And Toby is definitely a master."

Meltzer is so well-regarded in the industry for his results that patients wait more than seven months just to meet him for the first time. Indeed, if one were to schedule a surgery with Meltzer this very afternoon, it most likely would not be performed until late 2018.

With transgender awareness and health insurance coverage both expanding, a long wait isn't uncommon, says Jamison Green, president of WPATH. "We've seen an order of magnitude growth in demand because people are not so ashamed of who they are anymore," Green says, "and also because they can possibly afford to go ahead and have the surgery."

As recently as 1994, "transsexualism" was listed in the American Psychiatric Association's Diagnostic and Statistic Manual of Mental Disorders as a mental illness. The definition has since shifted toward medical: After changing the term to "gender identity disorder," the association in 2013 dropped its mention of a disorder for "gender dysphoria." The condition, in which one's expressed gender differs from the gender others would assign to him or her, isn't itself a mental disorder. But because it can cause mental distress, gender reassignment surgery is listed as treatment.

Reliable statistics aren't available, but Green says a 2006 survey suggested 1,200 surgeries were performed annually in the U.S. That number has likely jumped as the surgery recently has become far more affordable. Medicare lifted its ban on coverage for the procedures in 2014, and Green says two-thirds of Fortune 500 companies now offer coverage (although cosmetic procedures, like facial feminization, typically aren't included).

For Meltzer, that means about 90 percent of his patients are covered by insurance and 10 percent pay out of pocket - a monumental shift from the many years when the opposite was true, and a patient needed $24,000 for a first-stage male-to-female surgery alone. But the supply of surgeons qualified to do the work hasn't kept pace with demand. Green knows of only about 15 experienced surgeons nationwide - not that other, less qualified "specialists" aren't operating, too.

In the absence of formal training programs and licensure, any doctor can claim to be a gender reassignment expert. Inexperienced doctors are offering patients a surgery wait time of months or weeks instead of years - and many patients who have already waited years or decades snap up the opportunity. Meltzer says less than 3 percent of his female-to-male patients and virtually none of his male-to-female patients suffer major complications, which isn't the case for less-experienced surgeons.

"We get calls all day long from people who have bad outcomes from other places who are desperate to be fixed," he says.

Over the years, Meltzer has declined dozens of requests from surgeons requesting his tutelage. Only last year, as he began to realize his workload was unsustainable, did he find the perfect protégé.

Destiny's Doctor
Plastic surgeon Dr. Eleazar Ley considered learning gender reassignment surgery a decade ago, researching practices as far as Thailand. Like Meltzer, he had a fitting combination of skills - trained in craniofacial, hand and microsurgery - and continually sought his next challenge.

A single, seemingly innocuous moment made Ley realize that his interest in the surgery was more than professional. One day several years ago, while his wife was at work, Ley agreed to paint the fingernails of their two young daughters. To make fun of his shoddy work, he turned the polish on himself. That's when it hit him.

Always, Ley had felt something missing in his life. His search for fulfillment motivated him to emigrate to the U.S. from Mexico; to complete medical school, residency and three fellowships; and to start a private plastic surgery practice in Tucson. But not until the nail polish moment did he recognize what was amiss: his gender.

"It just stirred something inside of me that wouldn't stop, this force," Ley says now. "It was relentless after that. My feminine side just completely came out."

Ley, 42, last year became Ellie Zara, a slim woman with shoulder-length hair who wears dresses and heels to work. While the transition has brought pain and the end of her marriage, Ley says she's never felt such peace, like she's been female all along. And when Meltzer, after months of discussions, asked her to join his practice, "It just felt like destiny," she says. "That this is what I was meant to be doing."

Ley closed her Tucson practice and moved to the Valley, where she has been shadowing Meltzer's surgeries since December. When he deems her ready, she'll take on her own patients, and when he retires in about 12 years, she'll take over the practice.

She has shared some details when asked, but Ley doesn't use her transgender background as an ice-breaker with patients, no more than any doctor would begin a consultation by reciting their own personal health history. (Two other surgeons in the U.S. are openly transgender.) Ley wants patients to see her for the reason she was hired: her surgical expertise. But she hopes her experience gives her an advantage - in helping patients.

"I think I can sincerely encourage them that things are going to be OK," she says. "There's a reason we do this, and it's worth it."

The Confirmation
For decades, David Rose felt like an actor playing the role of a man. On his college wrestling team, in his marriage and in his IT consulting work, no one knew that a man who looked and acted so masculine had identified with women since his earliest recollections.

Rose, like many of Meltzer's patients, didn't find it personally and socially feasible to transition to Donna until age 40. Some wait even longer: A 70-something patient asked Meltzer to finish the surgery even if he died in the operating room. He wanted to be buried as the man he was.

Meltzer's work, which included numerous facial procedures, has allowed Rose to achieve what she never thought possible: acceptance, from society and from herself.

"All you want to do is look in the mirror and see who you perceive yourself to be looking back. You want to go to the gym or get a job or be left alone when you go shopping," says Rose, now 57, of Chandler. "That's what this is all about. Just living."

Meltzer emphasizes that surgery doesn't turn patients into different people. Many of them were exceptionally accomplished long before meeting him. They include two Fortune 500 CEOs, three Olympians, a White House staffer and a number of high-achieving software developers, pilots and military veterans, people who were uncommonly driven to compensate for the void in their lives.

What surgery changes is their ability to fully be themselves. That's why Ley prefers an emerging term for the surgery: not sex change, but "gender confirmation."

"The surgery itself isn't the thing that's going to change that person. You're already there, and you're simply doing something physically to make it match," Ley says, "to confirm who you already have been."

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world professional association for transgender health

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american psychiatric association’s diagnostic and statistic manual of mental disorders

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philadelphia center for transgender surgery

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Dr. Toby Meltzer turned Scottsdale into a worldwide destination for gender reassignment surgery almost by stealth. His new partner and protégé may change that. As a brilliant young surgeon, Dr. Toby Meltzer was capable of performing the most complex of plastic and microsurgery procedures: on hands, on nerves and blood vessels, on faces damaged by cancer or car accidents.

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In transition: OHSU evolves to aid transgender patients | OregonLive.com

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In transition: OHSU evolves to aid transgender patients | OregonLive.com

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The job was so new Amy Penkin didn't have business cards yet. She wasn't sure, exactly, what tasks awaited her. She understood only that she had to convince transgender people it was safe to visit a place many fear: The hospital.

Oregon Health & Science University leaders hired Penkin in early 2015 to lead an unprecedented cultural overhaul. They asked her to transform a system with 15,000 employees and nearly a million annual patient visits into a place that drew in transgender people rather than scared them away.

As more transgender people come out, much of the country is navigating new cultural norms. Families are learning to use new names and pronouns. Schools are adapting bathroom rules, and businesses have adopted new anti-discrimination policies.

But those changes are happening slower in health care facilities, where privacy concerns and a lack of clinical understanding have stunted the progress. Hospitals are among the most complex and bureaucratic organizations in the country. Tweaks do little to reshape them.

Even as more insurance companies cover gender transition, patients still say they can't find doctors to provide the services. They still feel medical staff discriminate against them.

No other major U.S. hospital had attempted the transformation OHSU leaders asked Penkin to lead. Portland, OHSU leaders thought, could be different.

Penkin decided to start by learning what hadn't worked. So last January, she made a bare-bones flier and headed to a downtown meeting where more than 100 transgender people swapped health care horror stories.

Young trans men, bulked up from time at the gym, leaned against a wall, arms crossed. A 75-year-old trans woman sitting in the back told another woman she hoped to begin hormones but worried doctors would treat her like a man in a dress. The last time she had visited a clinic, the receptionist called out her old, male name to beckon her back.

A woman recounted the time she went in for a cold and a doctor asked about her genitals. A man said physicians had chastised him for wearing bandages to flatten his chest.

Penkin laid the fliers on a table. She hadn't included any photos, just a list of legal and medical services she could provide or help patients find along with her phone number.

The modest sheets, and Penkin's quiet presence, were supposed to offer hope.

More than 70 percent of transgender people nationwide say they have experienced serious discrimination in health care, according to a 2010 report by the LGBT organization Lambda Legal. A third of transgender Oregonians say they avoid going to a hospital when they are ill because of past experiences.

When OHSU doctors decided to try a new model, they didn't know how many transgender patients they would see. Few other hospitals could give advice. They began planning the new transgender health program at a time when only 8 percent of Americans were familiar with the term and Caitlyn Jenner was still known as Bruce.

But their timing was right.

Last year, clinics nationwide saw huge increases in transgender patients after Jenner's public transformation. The industry wasn't anywhere near ready for them. In Oregon and Washington, new Medicaid benefits covered the cost of gender transition for poorer patients, but the states have few providers willing to see them. Little research exists to examine the benefits and drawbacks of those treatments. And no U.S. medical schools offer comprehensive training for doctors who want to help patients align their physical bodies with their gender identities.

OHSU was better situated than others to seize that moment. But the challenge of shepherding a complex system through a historic social change proved to be more difficult than hospital leaders had imagined.

A year later, as other hospitals begin to follow their lead, OHSU staff are poised to provide what they lacked when they began: A road map.

For most hospitals, transgender healthcare is brand new. More than a third of the 2,000 hospitals analyzed this year by the Human Rights Campaign still offer no treatments whatsoever for transgender people.

That isn't true at OHSU. In 1917, psychiatrist and surgeon Joshua Gilbert performed a hysterectomy on Lucille Hart so that she might live as Alan Hart. The operation is one of the first recorded female-to-male operations in the country.

In the 1960s, a psychiatrist working there helped develop the nationwide protocols still used to evaluate people whose gender identity doesn't match their chromosomes.

Why, then, did transgender people fear visits to the Southwest Portland hospital?

For older transgender women, the distrust began in the 1990s.

Back then, OHSU employed one of only half a dozen gender reassignment surgeons in the country. Dr. Toby Meltzer operated on 150 patients a year, most of whom flew from across the country to see him. It was lucrative work: an Oregon Health Authority official estimated in 1998 that Meltzer's surgeries brought in about $1.5 million a year.

But Meltzer felt he earned that money in spite of the institution. Hospitals officials refused to guarantee Meltzer an operating room, he said. He said his patients often were booted off the schedule in favor of what hospital administrators considered more pressing procedures.

"You can't have someone who has taken five weeks off work, flown there, and tell them they can't have surgery," Meltzer said. "That's just cruel."

When Meltzer did manage to operate, he said hospital officials allowed his patients to stay just two nights -- not long enough to recover from the invasive genital procedures he performed.

"I literally had to roll them out of the hospital," he said. "I was going to all these little hotels to check on my patients."

Eventually, he moved his practice to Arizona.

A decade after he left, a new group of doctors decided to demand more of OHSU. Some, like Dr. Christina Milano, treated patients who had developed rashes after injecting silicone they bought on the black market.

For years, the family physician's work was "mostly undercover," Milano said. OHSU officials didn't hinder her practice the way Meltzer said they had with his, but they didn't expressly support it either.

That changed when a husband and wife -- both surgeons at the hospital -- started talking at home.

Dr. Daniel Dugi, a urologist, was seeing more trans women who were having trouble urinating after undergoing genital surgery abroad. Dr. Hema Thakar, a plastic surgeon and Dugi's wife, was receiving more calls from trans men who hated their breasts.

The couple felt Portlanders shouldn't have to leave the country for dangerous surgeries. Dugi and Thakar could expand their surgical offerings. But neither had had any formal instruction in how to treat or even talk with transgender patients.

"I didn't understand enough about the terminology or what people are going through," Dugi said. "I notice when people misgender my dog. As small as that is, it prompted me to think about how much more personal and offensive that is for a person."

One night after dinner, Dugi and Thakar decided to ask their bosses for help.

They met with a hospital diversity coordinator and Milano first. Soon, their small group expanded to include 20 patients, medical students, physicians and clinic managers.

Thakar suggested a program similar to one the hospital's breast cancer clinic used. Patients would visit one office and see an oncologist, plastic surgeon and therapist on the same day.

Transgender people said they didn't want to be set apart, sent to a building with "transgender" emblazoned on a sign.

The hospital needed more than a few savvy surgeons, the patients said. Transgender people wanted to feel safe visiting a cardiologist or the emergency department.

What OHSU needed, the committee decided, was one person who could guide both patients and doctors through the cultural transition. The team approached the hospital's executives and asked if they could hire someone.

Milano, Dugi and Thakar were so enthusiastic, so assured that it was the right thing to do, said Cynthia Grueber, the executive director of OHSU Healthcare, that the executives didn't even ask if their plan would make money.

The hospital didn't track how many transgender patients visited each year. The doctors suspected the number wasn't high, so the team created a position tasked with a job that reached far beyond patients.

They went looking for someone who could do more than make OHSU a better hospital. They wanted someone who could make life better for all transgender Oregonians.
***

The committee chose Penkin to coordinate the program as much for her personal experiences as her professional ones.

Penkin, a 45-year-old with a quiet voice and an easy smile, had managed social and health care programs, including one in San Francisco that evolved from a small clinic specialty to a citywide Transgender Health Services initiative.

And she understood why transgender people feared hospitals. As a teenager living in suburban New York, she knew transgender people whose doctors over-medicated them with anxiety medications. What they really needed, Penkin said, was "to be affirmed in their gender."

As an adult, she'd had close friends who went to the doctor with sinus infections and were met with probing questions about hormones and surgeries. When one visited an orthopedic specialist for his knee, a worker wrote TRANSGENDER at the top of his chart.

"It raised his anxiety," Penkin said. "Why does that have to be the first way that he is being viewed? Why can't he just be a person with a knee issue that needs attention?"

Surveys conducted by advocacy groups showed that transgender people feel slighted by doctors who ask about their chests or genitals, but a visit to the hospital is so much more than that one relationship.

OHSU employs more than 15,000 people working in 119 buildings across the state. Only a handful of those workers had any experience with transgender patients.

If Penkin was going to convince transgender patients that OHSU was welcoming, she'd need to train the woman at the information desk who gives directions to the bathroom, the nurse who makes small talk with patients while checking their weight, the workers who bring meals to people recovering from surgery.

Penkin believed most health-care workers didn't hurt patients' feelings out of malice but rather ignorance. Miscommunications that some might find innocuous -- calling someone by the wrong name, for instance -- deeply hurt transgender people who felt the missteps called into question their very existence.

She had seen "incredible successes" in San Francisco clinics where receptionists knew how to address transgender visitors.

"I'm driven by the good," Penkin said. "I'm not driven by the bad stuff that happens. It's way more motivating to be driven by what is possible."

In the spring of 2015, Penkin met 20 receptionists for a 7 a.m. training.

Sometimes, Penkin told them, transgender patients may seem irritated when they arrive.

"Imagine they have gotten lost," she began, a common occurrence on the sprawling campus. "And they're a transmale asking for the Center for Women's Health. And they're asked, 'Are you sure that's where you need to go?' Then they check in here at the front desk, and you're so busy you didn't see their preferred name and so you call them by their legal name."

The wrong name. A name that reminds a transgender male of the years he spent mistaken for a girl. A name that outs the patient to the entire waiting room.

The receptionists nodded and scribbled notes. One said she didn't want to make patients feel bad, but sometimes, the notes in their files are confusing. Just a few weeks ago, she had seen a confusing acronym in a patient's medical record.

"It had MTF or FTM on there," she said.

Penkin pulled up a slide. Those acronyms were shorthand -- MTF meant a biologically male patient had transitioned, or was in the process of transitioning to female. FTM indicated a patient had been designated female at birth but had, or planned to, transition to male.

The markers were new additions to the hospital's electronic records.

OHSU uses a patient records software used by more than half the nation's hospitals. Because so few health care systems offer transgender treatments, the software doesn't yet include space to chart a patient's gender evolution.

OHSU software engineers had spent much of 2014 customizing the program, adding in fields to note a patient's preferred name, biological sex and gender identity. The records could now document what clinicians called a patient's transition journey, indicating which organs the patient had removed or retained, which medications or surgeries they might one day want.

The new records provided valuable medical context. Men and women have different norms when it comes to lab work. Transgender women may still need prostate exams. Transgender men may need Pap smears.

The records also served as a directive for receptionists. A transgender male may have not legally changed his name. The record could remind receptionists to call out the preferred masculine name instead of the female moniker associated with his insurance.

But the upgrades were so new that in the spring of 2015 many hospital workers didn't know how to interpret them. And, Penkin learned, doctors used different configurations. The gender identity might show up in yellow or red. The "FTM" or "MTF" marker could show up in bold with a rectangle around it.

Penkin told the receptionists she had recently accompanied a transgender patient to a family medicine clinic that used a different software altogether. His paperwork printed off with a female name.

"I hand wrote his male-affirmed name and his pronoun on his label," Penkin said. "He was still misgendered and misnamed four times with me standing there."

The receptionists had booked Penkin for 20 minutes, but she stayed an hour. Together, they practiced ways to address someone whose gender isn't clear. She introduced them to a new hospital volunteer, Jay Rae, a 35-year-old transguy with floppy hair and a disarming grin.

Rae told the group he bound his chest and wore boxy, plaid shirts to appear more masculine. He didn't want to have surgery, so his driver's license still listed him as female.

"But I go by he," Rae said. "I'm a dude."

"You're going to mess up," he told the receptionists. "It's going to happen. Just apologize, correct yourself and move on."
***
By May 2015, every day in Penkin's calendar was booked.

One hour, she was helping a transgender medical student update an academic transcript to reflect their gender transition. The next, she was calling the hospital employees' insurance company to appeal after it refused to pay for a worker's chest surgery.

In between, she worked on what she jokingly called "the potty project."

Penkin knew many transgender people avoided restrooms the way they avoided hospitals. They worried about being kicked out or even attacked. Many feel safer in single-stall, gender-neutral facilities, but OHSU has only a few in its busiest clinics. Penkin suggested mapping them and changing the signs to better advertise the unisex stalls as transgender-friendly.

And then there were the patients themselves. Penkin started her job the same week that Oregon's Medicaid began paying for low-income residents to transition. A breast surgeon who had seen only 16 patients in 2014 suddenly had 50 scheduled. The wait to see a pediatric endocrinologist stretched to four months, as more than 100 transgender children came in for appointments.

Most Oregon hospitals didn't have a Penkin. They didn't have a Dugi or Milano, doctors who wanted to specialize in transgender care. As patients showed up in The Dalles and Klamath Falls, rural providers called Penkin for help. Regional Medicaid organizations called Penkin, too, hoping she could teach doctors in remote corners how to prescribe hormones.

"The whole state went into a tailspin trying to figure out what does this look like," Penkin said. "I think a lot of people just said, 'Oh, OHSU will do it.'"

But the hospital still had work to do.

When Meltzer left in 1996, OHSU stopped offering genital reassignment surgeries. No other Oregon hospital provides them, either. But Oregon's Medicaid now promised to pay for the operations. Without an in-state option, the public insurance would have to pay to fly patients to Arizona to see Meltzer at his new hospital.

Dugi, a reconstructive urologist, hoped to fill the gap. He offers complex genital surgeries that few others on the West Coast perform. Those procedures involve many of the same steps as those used to change male genitals into female genitals, but he needed to watch someone perform the surgery from start to finish.

There was only one way to do that: Leave the country.

U.S. medical schools don't offer the training, so Dugi spent 2015 traveling to Belgium and Serbia to train under the world's most lauded gender reassignment surgeons. Back home, he practiced on cadavers.

More than 100 transmen and transwomen called to schedule appointments with Dugi before the urologist even finished training.

Interest grew so quickly that OHSU executives decided to hire another surgeon. But few doctors had the required experience or skills.

OHSU executives found a uniquely qualified Johns Hopkins University resident. Unlike most established surgeons who attended school without ever hearing about transgender patients, Dr. Jens Berli had focused his study on the care and even performs a variety of gender reassignment surgeries at the University of Maryland. He spent his vacations training in Belgium and Thailand.

He wouldn't finish his residency until the summer of 2016, but OHSU hired him. When he arrives in July, he will perform facial, chest and genital surgeries, including the complicated procedures to construct penises for female-to-male patients.

By the end of 2015, Penkin had trained or talked with more than 2,000 employees and counseled about 500 patients and their doctors. She had helped reshape Oregon policy and organized a daylong workshop for Portland doctors and therapists who accept Medicaid.

Other hospitals were adapting, too. Legacy Health had appointed a group of doctors to plan a transgender health program there. Even Providence Health, a Catholic non-profit hospital system, had hosted trainings so some of its physicians could learn about transgender issues.

OHSU was ahead of the pack, but still had a long way to go. The "potty project" was in limbo, hamstrung by the rigorous design standards of a large institution. The upgrades to the medical software didn't allow nurses to print a preferred name on in-patient wristbands. And most employees still hadn't gone to a training.

That December, Penkin ended the year the way she had begun it, by meeting with a group of transgender people.

This time, they met at the hospital.

"I really underestimated how much there is to do, and how limited I would be as one person," Penkin told them. "We have this broad vision and mission to improve the health and wellbeing of all transgender Oregonians, and we have an infrastructure of ..."

She trailed off for a few seconds then smiled.

"Me."

The group laughed. Penkin had taken only three vacation days in 2015, but one person can't change a giant institution.

Penkin needed a volunteer to make a list of therapists who would accept transgender clients. She wanted someone to map out the unisex bathrooms and another to find out how much hormones and surgeries cost for people without insurance. Plus, she was looking for help updating the website, planning community events and calling commercial insurance companies to determine which might pay for transition.

Eventually, she'd have volunteers and, if the budget committee approved it in June, three staff members.

For now, Penkin leaned back in her chair and surveyed the room. Everyone was smiling. That, at least, was progress.

-- Casey Parks

503-221-8271

cparks@oregonian.com; @caseyparks

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In transition: OHSU evolves to aid transgender patients

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The job was so new Amy Penkin didn't have business cards yet. She wasn't sure, exactly, what tasks awaited her. She understood only that she had to convince transgender people it was safe to visit a place many fear: The hospital. Oregon Health & Science University leaders hired Penkin in early 2015 to lead an unprecedented cultural overhaul.