Editor's note: Many trans people prefer not to use their "deadname" or associated pronouns, or discuss the details of their transition, including surgeries. The people in this story have, however, agreed to be identified as they are here and to share their personal details.
One night in 2012, Jeannot borrowed $10 from a friend and drove from their home in a Dallas suburb to a lesbian nightclub in the city. At the time, Jeannot, who uses they/them pronouns, was a 24-year-old stay-at-home mom who wore girdles and aprons, did up their hair in pin curls, and served their husband casseroles made from family recipes.
They were also deeply unhappy in a way they could only describe as feeling like they'd been hired for a job they weren't right for: the job of being a woman. When they shared that feeling with the faith-based mental health counselors at the fundamentalist church they and their husband attended, they advised Jeannot to pray. When Jeannot talked with their gynecologist, the doctor offered multiple diagnoses and psychotropic medicines. Jeannot donned aprons and curled their hair in the hope that performing hyperfemininity would please their loved ones and ease the discomfort. But nothing helped.
They went to the club that night in search of escape and kindred spirits. Minutes after they arrived, they saw an "ethereal goddess of a human being" come onstage to play piano and sing—and fell instantly in love. Experiencing that love, the only thing besides the connection to their children that felt natural at the time, was the first step of an epic journey that led Jeannot away from everything they knew, toward a life, an identity, and a body they couldn't imagine at the time.
Five years later, by the time Jeannot Jonte Boucher—who also goes by Johnny—flew from Dallas to Baltimore for a consultation with Johns Hopkins plastic surgeon Devin O'Brien-Coon, they had a name for the debilitating discomfort they'd felt all those years: gender dysphoria. And they had language to describe what they'd discovered was their true identity. Boucher is a nonbinary transmasculine person, which means they identify mostly—but not exclusively—as male. Since 2012, they had ended their six-year marriage to their children's father and married Ashley Boucher, the trans woman they'd seen performing that night at the club. They started taking testosterone and underwent a mastectomy. They also earned a master's degree, became a teacher in the Dallas public school system, and campaigned for a seat on the local school board as an openly trans candidate. But despite the radical transformations, Boucher still couldn't express their identity in their body. That was the reason for the trip to Baltimore. "I wanted to see myself dressing or showering and feel comfort like you do when you expect to see your arm there, and you do," says Boucher, 33. "I wanted to look down and see my body how I expected it to be, healthy and whole."
Five years of struggling to get medical care as a trans person in Texas had resulted in lowered expectations. Every endocrinologist Boucher had asked to manage their hormone therapy had replied with some version of, "We deal with families here"—meaning trans patients weren't welcome. They were forced to visit a "doc in a box," where the provider, who knew nothing about testosterone dosing, simply copied a prescription Boucher had found online.
They expected to be in and out of Coon's office within 15 minutes. So no one was more surprised than they were when Coon spent more than an hour listening closely to what they needed, before offering a detailed plan to achieve it. "He's the first physician I'd met who saw me as a whole person," says Boucher. "He's not just going through the motions. He's planning with me, making my self into flesh in a way that's just for me."
Boucher left Baltimore that day knowing that Coon was the right person to perform their phalloplasty, a multistage surgery that occurs over the span of a year, at the end of which they'd have a functioning penis. They also knew there was a waitlist as long as two years to even get scheduled for surgery. But one month later, Boucher got a call saying there was an opening in Coon's schedule. And in December 2017, they became one of the first patients to undergo phalloplasty at the nascent Johns Hopkins Center for Transgender Health.
Boucher wasn't one of the first patients to get phalloplasty at Johns Hopkins itself. A half-century before the Center for Transgender Health opened in 2017, Hopkins became the first hospital in the nation to perform what were then called sex reassignment surgeries through a multidisciplinary initiative called the Gender Identity Clinic. The GIC, as it was known, was radical, groundbreaking, and controversial from the start. "The great majority of people associated with Hopkins looked very much askance at the program," recalled former GIC chairman and plastic surgeon John Hoopes in a 2006 interview. "Everyone was wondering why we were involved with those 'queers,' as they called them."
The 10 GIC members—including legendary gynecological surgeon Howard Jones, plastic surgeon Milton Edgerton, and psychologist John Money—were united in their belief that surgery could provide psychological healing for trans patients who were suffering. The biggest problem, Hoopes says, "was deciding who was a candidate for surgery and who was not."
To help distinguish what GIC members labeled "true transsexuals" from those they believed were mentally ill, patients were required to meet a list of criteria that included everything from being evaluated by multiple psychiatrists to dressing as their desired gender for six months, a rule that endangered patients in the many areas of the country where crossdressing was a crime. Many trans people viewed the criteria as pathologizing and unfair, and came to see the Hopkins doctors as hostile gatekeepers who denied treatment to all but a few. In the first three years of its existence, the GIC received 1,500 requests for surgery and performed 20. Ten years later, by 1979, it had performed just 100.
That same year, Hopkins psychiatrist Jon Meyer published a follow-up study of a portion of those 100 patients that he said proved the surgeries performed by the GIC did not improve patients' quality of life. Meyer's research was encouraged by psychiatrist Paul McHugh, who had joined Hopkins in 1975 to become director of the Department of Psychiatry and Behavioral Sciences with a mission to end gender affirmation surgeries, a practice he viewed as "collaborating with madness." Armed with Meyer's study—which was later roundly criticized—and in the absence of resistance from Jones and Edgerton, who had both left Hopkins by then, McHugh succeeded in his mission. The demise of the GIC set off a chain reaction at academic medical centers nationwide, ending not just surgeries but also research, evaluation of outcomes, and education.
Starting around 2007, Richard Redett, director of the Johns Hopkins Department of Plastic and Reconstructive Surgery, and his colleagues began talking about restarting what are now called gender confirmation or gender affirmation surgeries. "We knew the need was quite high," Redett says. "We were performing a significant number of genital reconstructions in children and young adults with congenital conditions and felt we had the expertise to translate this type of care to transgender patients." But few health insurance policies covered the procedures, and few patients could afford the out-of-pocket fees that run as high as $100,000.
But in 2016, when the Obama administration published a final ruling on the Affordable Care Act that made it illegal for most insurers to deny or limit coverage based on gender identity, restarting gender affirmation surgeries became economically feasible. When Redett and department chair Andy Lee took the idea to Lisa Ishii, senior vice president of operations at Johns Hopkins Health System and a professor of otolaryngology, she saw an opportunity to go beyond a surgical program and create a center for transgender health. Like the GIC, it would be multidisciplinary, incorporating urology, gynecology, endocrinology, dermatology, mental health, and other departments, along with plastic surgery. But unlike the GIC, it would have the full support of the Johns Hopkins Health System, and would be designed from the start to provide superior care to an underserved population in a gender-affirming setting.
Ishii asked Paula Neira, then a nurse educator in the Department of Emergency Medicine, to co-chair a task force to plan the structure and scope of the center. A trans woman who transitioned in the 1990s, Neira had firsthand experience with the health care inequities the center was seeking to address. As a lawyer and officer in the U.S. Navy, she'd been a leader in the fight to repeal "don't ask, don't tell."
Neira knew that because of the GIC's complicated history, many trans people did not associate Hopkins with phrases such as "gender affirming." The best way for Hopkins to rehabilitate its reputation in the trans community, she says, is to "train providers, increase access to care, and do research so that we can provide better care for trans patients and reduce health disparities and health inequities."
When the task force surveyed trans people nationwide, they learned the most urgent need was for gender affirmation surgeries, including hysterectomy, top surgery (mastectomy or augmentation), facial feminization and masculinization procedures, and bottom surgery (vaginoplasty and phalloplasty). Neither Redett nor Lee had the capacity to be the center's full-time surgeon so they tapped Coon, who'd come to Hopkins in 2010 as a resident in plastic surgery. As a senior resident, Coon had assisted on gender affirmation surgeries at University of Maryland Medical Center, where he first encountered trans people's stories of suffering and discrimination, and the surgical procedures that could transform their lives. When he became the chief medical director and main surgeon at the Center for Transgender Health, he experienced a 21st-century version of the reactions GIC members had heard from colleagues in the 1960s. "I had a ton of people ask me why I was throwing away such a promising academic career," says Coon, 38. "Even those people who said they had no negative feelings against trans people wondered if it was a smart career move for me to focus on people 'on the margins of society.'"
But for Coon, helming the Center for Transgender Health meant he could make a significant impact as an advocate, doctor, and scientist. As an advocate, he spreads the message that trans patients are not different from other patients except that they've been marginalized by the health care system. As a doctor, he performs surgeries that are so transformative that some patients change the day they celebrate their birthday to the date of their surgery. And, as a biomedical engineer, he develops technologies to improve outcomes of those procedures.
"There's the humanitarian aspect of advocating for treating people equally. And there's the medical aspect, trying to improve the quality of the medical care we provide trans people," he says. "Gender surgeries are the Wild West. They're some of the most technically complex and demanding surgeries of any kind, but a lot of them are still being perfected. We're trying to raise the bar on everything."
Once Boucher learned that their phalloplasty was scheduled for December 2017, they panicked. Not because of the surgery itself—they trusted Coon completely—but because in order to get cleared for surgery there was "a marathon of hurdle-jumping" to complete that included securing what are called "letters of readiness" from two different mental health practitioners. This requirement, which is part of the Standards of Care outlined by the World Professional Association for Transgender Health, is an artifact from an earlier era when patients had to supply evidence of their sanity in order to be deemed "good candidates" for surgery, says Neira, the center's clinical program director. "Gender identity disorder was removed from the Diagnostic and Statistical Manual of Mental Disorders in 2013, in the same way homosexuality was removed in 1973," she says. "We shouldn't make transgender people have to talk to mental health providers when there are no mental health issues involved."
For Boucher, who'd already had terrible experiences trying to secure a letter from a therapist in order to get a referral for hormone therapy, it was one of the most stressful experiences of their life. "I'm just meeting this person one or two times, and they have so much control over my life," Boucher says. "I'm thinking, 'What does this person want to see? What do they want to hear?' I was worried if they put that I was nonbinary in the letter, the insurance company might not believe my phalloplasty was medically necessary."
With the help of center coordinator Melissa Noyes, Boucher cleared the hurdles, and on December 17, 2017, Coon performed the first of the three stages of Boucher's phalloplasty. During the 14-hour operation, Coon removed a roughly six-inch square section of tissue from Boucher's arm. He formed that tissue into a penis-shaped tube that he attached to Boucher's groin by painstakingly sewing together vessels under a massive surgical microscope. Using sutures smaller than a human hair, he connected one artery, two veins, and three nerves, all of which would ensure that the transplanted tissue would receive sufficient blood flow to remain healthy, and that Boucher would have functioning nerves that would allow for the experience of sensation in their penis.
Post-surgery, Boucher stayed in the ICU for two days before being transferred to an inpatient room where they lay motionless for five more days, their arm in a splint and legs separated and immobilized. After discharge, they had to stay in Baltimore six more weeks for post-op visits. It was painful, and Boucher missed their wife and children, who were then 7 and 9 years old, and the preschool and kindergarten students in their Montessori class. But, they say, "I was ecstatic to be having these procedures."
In March 2018, Boucher returned to Hopkins for phalloplasty stage 2, which included a hysterectomy, scrotoplasty (the creation of a scrotum including testicular implants), and glansplasty (the sculpting of the head of the penis). Typically during stage 2, a urologist or gynecologist removes the patient's vagina and Coon completes the urethral lengthening that allows the patient to pee through the tip of their new penis. Boucher did not have these procedures because they wanted to keep their natal sex organs.
There were complications following stage 2: an infection in the testicular implant, which had to be removed, and temporary neuropathy that made it hard to walk. Coon advises all phalloplasty and vaginoplasty patients that the complexity of the surgeries means it's likely that a patient will have complications at some point on their journey. So Boucher was disappointed but not surprised. "I felt like a work of science fiction where they're rebuilding the pieces that didn't take and fixing you back up," they say. Even with complications, Coon says that more than 90% of the center's phalloplasty patients reach their end goal.
In December 2018, Boucher underwent the final stage of phalloplasty, in which an implant and pump were inserted into their penis so that it could be used for penetrative sex. For Boucher, it was a year of both extreme physical discomfort and emotional comfort they didn't know was possible. "It is as if any other essential part of my body were returned to me, which by some accident of birth was never formed," they wrote in a post-op diary.
When Boucher underwent micropigmentation of their phallus so it would look more natural in color, they made an extra request of the tattoo artist: to add a tiny tattoo of Coon's signature, as if he were an artist signing his work. "Dr. Coon took my thoughts about my body and transformed them into flesh. Rather than removing my gender dysphoria, he gave me gender euphoria," Boucher says. "I feel like his medical skill is an art form."
Since Boucher's surgery in 2017, Coon has performed nearly 500 gender affirmation procedures and gained a reputation as one of the top gender-affirming surgeons in the country. "The Canadian government sends patients here," he says. He has a three-year waitlist for phalloplasty. And Coon has answered those who questioned his career choice by becoming the youngest member of his department to ever be promoted to associate professor. He did it in under three years.
Image caption: Devin O’Brien-Coon
Image credit: WILL KIRK / JOHNS HOPKINS UNIVERSITY
When the COVID-19 pandemic halted the center's inpatient elective surgeries for three months starting in March 2020, Noyes had the difficult job of informing patients. "There were so many conversations when I cried. The patients feel these surgeries are not elective—they're medically necessary," she says. "This patient population has been so incredibly disenfranchised from health care and the delay smacked to a lot of people of disenfranchisement."
When Hopkins again stopped inpatient elective surgeries in December owing to a spike in COVID-19 infection rates, Coon and Neira successfully advocated to continue the center's surgeries. "We had to get creative," Coon says. "We trained the nurses on the plastic surgery floor to work with our patients after surgery so they don't have to go to the ICU."
When he's not in the operating room, Coon works to develop techniques and technologies to improve outcomes for trans patients everywhere. In his lab at the Johns Hopkins Translational Tissue Engineering Center, he and his team work on novel ways to create tissue so one day surgeons can perform phalloplasty without having to harvest tissue from a patient's leg or arm. He also studies the effects of sex hormones on wound healing, which he believes will become a significant factor in surgical planning. And he and his team recently completed a nearly four-year review of every study on gender affirmation surgery published since the 1960s. It's the largest review of transgender-related research that has ever been done, and it was recently accepted into the prestigious journal Annals of Surgery.
"What makes Devin unique is that he's one of the few scientists in the world working in this area who are also doing these surgeries," says Jennifer Elisseeff, director of the Translational Tissue Engineering Center. "There are very few people who do that in any field."
Drawing on his biomedical engineering background, Coon collaborated with renowned Hopkins radiologist Elliot Fishman to create a three-dimensional urethrogram that makes it possible to visualize the entire anatomy of a surgically created phallus and more effectively detect fistulas and strictures, common complications from the urethral lengthening. He also invented a 3D ultrasound imaging system to easily measure blood flow at a patient's bedside after microsurgery, a device that won FDA approval and is now in clinical use.
The Center for Transgender Health talks to @usnews about the rise in gender affirming surgeries due to societal acceptance and insurance coverage. https://t.co/vJCGfKYj5N pic.twitter.com/LuwaRzejgm
— Johns Hopkins Medicine (@HopkinsMedicine) May 31, 2018
Of all the gender affirmation procedures Coon performs at the center, facial feminization and masculinization surgeries are the most high-tech. In 2019, he performed facial feminization on Emily, a 34-year-old Pennsylvania woman who works in the food and beverage industry, by using CT-based technology to create a virtual model of her face, plan the surgery, and translate that plan to a 3D printed titanium guide that snaps onto the patient's skull. "We used to just look at a patient's picture and try to adjust the bones accordingly to get the desired effect," Coon says. "Now I can execute with very high accuracy—within a millimeter—the plan that I made on a computer." Over the course of two surgeries, Coon performed forehead reconstruction, brow and orbital rim contouring, rhinoplasty, jaw contouring, and fat grafting to Emily's cheeks and upper lip. He also used 3D technology to print custom titanium implants for her cheeks. "I looked at myself afterward and thought, 'Ah, yes. I'm there,'" Emily says.
Facial surgery is often not covered by insurance companies, which define it as "cosmetic" despite the fact that for some patients it is as effective at relieving gender dysphoria as top or bottom surgery. It's also a safety issue. "If you think about how much more likely violence and assault are for trans women than the general population, not being able to get facial surgery puts you in the most danger because it directly impacts your ability to 'pass,'" Noyes says. The same goes for voice therapy and voice surgery, both of which are not seen as medically necessary by many insurance companies.
"Voice is a meaningful component of identity," says Ashley Davis, a speech language pathologist in the Department of Otolaryngology who sees several patients each week for gender-affirming voice therapy. "From a gender standpoint, it's huge. Someone can look perfect walking down the street, but if they open their mouths and are misgendered, it's a huge thing."
Even after she transitioned and was passing as a woman, Emily's voice caused her to be misgendered, especially when she played guitar and sang in clubs—so she stopped singing. Soon after her facial surgery, she had voice surgery performed by Simon Best, an associate professor of otolaryngology, in which he shortened the length of her vocal cords to raise the pitch of her voice. Now she is singing again. "It was a piece of cake surgery with a big impact," she says.
Emily knew she was transgender ever since she was a boy named Lennon who was punished by his parents for dressing in his sister's clothes. By the time she moved out of her parents' house and started living fully as a woman, she also knew that if she ever wanted to feel comfortable in her own body, she would need genital surgery. She started saving money in 2010, after she got her first job. Six years later, she'd amassed the roughly $25,000 she needed to travel to Thailand to have vaginoplasty, in which a surgeon would remove her penis, testicles, and scrotum, and create a vagina and labia. Then she learned that the health insurance she had through her job would begin covering gender affirmation surgeries starting in 2017. So she canceled her Thailand appointment and scheduled surgery with the lone in-network surgeon who provided vaginoplasty. She was ecstatic. She was finally getting the surgery that would allow her to date, hopefully fall in love, and find a partner—and she wouldn't decimate her savings to do it. But after both her original vaginoplasty and a revision surgery failed to result in a functioning vagina, Emily had to deal with pain and disappointment, and the difficulty of finding a provider to treat her complications.
"I went to several gynecologists and once they found out I was trans, they didn't want to deal with me," she says. She went to two doctors who specialized in skin grafts but neither had any experience with vaginoplasty. At one place they asked if she was willing to have students come in. "I said, 'Sure.' And all the students came in and looked—and then the doctor said, 'I can't help you.'"
Inspired by the success of her facial and voice surgery, in 2019 she asked Coon to perform a second revision of her vaginoplasty. Nearly one-fifth of the gender affirmation surgeries Coon performs are revisions of procedures done by surgeons at other hospitals and private practices. "Right now there's no way for patients to know if doctors who say they do these surgeries have any idea how to do them," Coon says. "For new surgeries that didn't exist before, the medical system doesn't have an easy way of certifying training. If a new surgery comes out, it's usually an extension of another field. But genital surgeries—disassembling and rearranging a male genito-urinary system, for example—are not similar to anything else. It's a 'black swan' event in the medical system to have this new field appear this late in the game." Coon says the surgeries he often has to revise are the result of a lack of training, which is why the center started a surgical fellowship program in 2019.
After a November 2020 operation in which Coon improved the external aspects of her vaginoplasty, Emily was so heartened that she decided to undergo yet another surgery, a robot-assisted procedure Coon will perform with urologist Heather DiCarlo, that she hopes will make her vaginal canal functional for intercourse. She's already undergone three vaginoplasties—each with its own aftermath of discomfort, time off work, emotional hardship, and recuperation—but she is going ahead with the fourth surgery, tentatively scheduled for later this spring. "People say you're so strong, you're brave," she says. "I say, no, I'm doing it because I have to. It's something I have to do to feel like myself."
Kiran Jenkins, 33, came to the center for a revision phalloplasty in August 2019 after undergoing a botched surgery from a doctor in Washington, D.C., who claimed to have performed the procedure before, but hadn't. During the year he waited for his body to heal and his surgery date to arrive, he worked hard to stay positive. "I'm pretty sure if a person in that situation wasn't as strong as me, they might have really struggled or taken their own life," he says. The botched surgery left significant scar tissue, and Jenkins worried Coon would have difficulty performing his phalloplasty. But when he woke up in the ICU after phase 1, Coon, one of the few surgeons in the nation to perform revision phalloplasties, was at his bedside to show him his phallus and let him listen to the blood flow through the ultrasound. He underwent stage 2 in August 2020 and discovered the "joys" of peeing standing up. And after he gets stage 3 this spring, he'll have a penis that will enable him to have sex with his wife, Melanie.
Jenkins and Melanie recently moved into a rowhouse in Baltimore, and they're hoping to have their first child soon. "My main focus is to live a normal life," he says.
That's the message Coon delivers wherever he can. "My hardest mission is going to serious professional and academic settings and trying to sell people on the idea that trans people are normal people like them," he says. "They're looking for ways to say these are 'others,' they're not like us. That's a battle I've been waging."
He also wages a continuous battle to get the center the resources it needs to provide a full spectrum of care for transgender patients. Neira would like to have a staff mental health therapist offering treatment, not just surgical evaluations, and a dermatologist to provide electrolysis, which is required for bottom surgery. She would like the center to provide primary care in Western Maryland and other underserved areas in the state, and offer training in transgender health for all Hopkins care providers.
Neira knows the center can do more, but she also understands what it takes to make changes in a large system. "The motto that I came up with for the center is Semper Porro—that's Latin for 'ever forward,'" she says. "Even if it's slow, even if it's uneven, we're making progress." Which is to say that the center is on a long journey, full of obstacles, something nearly every patient who seeks care there intimately understands.
Also see
Boucher is still on their journey. Three years after that first phalloplasty surgery, they are hoping to undergo facial surgery with Coon. They want to drive from their home in Dallas out to the countryside and not feel at risk of being outed as trans. They want to decide when, how, and with whom to share their medical history, rather than having the shadows cast by their brow, the amount of fat in their cheeks, or the angle of their nose send the wrong message about their gender. They want to work as a school administrator without children asking if they are a man or a woman. And, yes, Boucher recognizes the irony: If they had been less pretty as a woman, they wouldn't struggle with how feminine their features remain even after years of testosterone.
For now, though, surgery has to wait. Their wife, a chef, was laid off owing to the pandemic, and Boucher's insurance through the state of Texas doesn't cover gender affirmation surgeries.
Boucher is grateful that their 12-year-old daughter, who is trans, is able to take medicine to block the testosterone her body would produce during puberty. "She will probably not need facial surgery to undo what testosterone would do to her face," Boucher says. And they are grateful that they don't have to worry about her like they used to.
"One of my fears was that my daughter would get bad medical care, get taken in by a crank or fake therapist," Boucher says. "Knowing that this Hopkins center exists and will be there for her when she needs it has eased my worries. There are medical guardians out there doing the right thing."
An earlier version of this article misstated Johnny Boucher's preferred pronouns and misidentified their official full name. The magazine regrets the error.
