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January 10, 2019

Terrell Smith feels like a late bloomer. A transgender man who recently completed his physical transition, he says his strict religious upbringing and desire to fit in made his adolescent feelings that "something just wasn't right" confusing and frightening. However, Terrell now smiles broadly and punctuates his conversation with laughter as he talks about his journey, a man who is obviously comfortable in his own skin.

"It's been a long time coming, but I finally feel like I’m learning to be who I’ve always been," he says. Working with staff and physicians at The University of Kansas Health System in Kansas City, Kansas, Terrell says he's "come home," both to himself and to a supportive medical community who oversaw his physical transition and continues to provide ongoing care.

An uncomfortable childhood

Born with female anatomy, Terrell says his childhood and teen years were marked by internal emotional battles and family conflict. "I knew what I was 'supposed' to do, and it wasn't what I felt I should do," he says. "When I came out as a lesbian to my parents when I was 16, they basically tried to lock me up and pray the gay away."

It didn't work. Terrell thought if he had a relationship with a male, he might feel differently. A single heterosexual encounter left him pregnant, the situation in his home worsened and he left his parents' house at 17. His son was born the following year.

Terrell floundered through the next few years. "I got myself into trouble and ended up in jail," he says. His parents took custody of his son, then 3 years old. Once his sentence was served, Terrell emerged with a new resolve and new goals.

"I fought like hell to get my son back and was able to get custody when he was 7. I started community college and became a certified nursing aide. I got additional training in nephrology and I've been working with dialysis patients for eight years."

The transgender revelation

As he focused on his career and raised his son, Terrell had a life-changing revelation. "I learned what it means to be transgender when I was 28 and the pieces fell into place," he says. Always uncomfortable with his body, Terrell recalls getting into trouble when he tried to use the bathroom standing up as a child.

When a female transgender friend shared her story, Terrell realized "it sounded just like me in reverse. That's when I started researching and found that everything I felt matched with the description of what it means to be transgender."

Terrell's age during this realization seemed late to him, but Kimberly Vandegeest-Wallace, PhD, a clinical psychologist with the health system, notes that individual transgender journeys are as unique as the individuals themselves. There is no right age or circumstance when it comes to transitioning.

"There’s a reason the 'Q' in LGTBQ can mean 'questioning,'" she says. "Many people try very hard to conform to societal binary norms when it comes to gender identity. They do what they think they're supposed to do. But deep down, they know they can’t be themselves in the way the world expects."

Terrell's research, while confirming his conviction that he was truly male, was also disheartening. To physically transition would not be cheap and he wasn't in a financial position to pay out of pocket. He also worried that transitioning while raising his heterosexual son would be confusing and stressful. "I suffered," he recalls. "But I promised myself I'd transition when my son was grown."

When his son left for college, Terrell kept his promise. He began by seeing a counselor at the Transgender Institute Foundation in Kansas City and was referred to The University of Kansas Health System. He knew that taking testosterone was just the first step. Surgery would be the next phase, and the looming changes made him nervous. "I have some trust issues, so just making an appointment was a big deal," he says.

When Terrell stepped into the consultation room, he wasn't sure what to expect. Would there be judgment? Would he be put into a standardized program? Would he be discouraged?

Following an individual path

"The minute Judy Gay walked in, I felt at home," Terrell says with a broad smile. "She was the most welcoming person. She told me it would be OK and she would help me every step of the way. It was the first time anyone had offered that kind of support."

An experienced nurse, Gay began working in this specialty at the health system in 2016 and serves as its full-time coordinator. She notes that the staff members are a tightly knit group dedicated to serving the transgender community and following the World Professional Association for Transgender Health (WPATH) standards of care.

"Each person's path is individual, so there's no cookie cutter route," she says. Gay helps patients determine where they are on their individual journeys and what their goals are. A personalized plan follows. To adhere to WPATH standards of care, patients must have two letters of recommendation from mental health professionals before scheduling surgery. One letter is required for those who need to begin hormone therapy.

"We connect patients with appropriate mental health providers for consultations," Gay says. Once the letters are received, patients meet with their medical team. "We begin the process of medical preparation and surgical planning, and we become lifelong friends along the way."

After his reassuring visit with Gay, Terrell's next introduction at the clinic was to Meredith Gray, MD, a board-certified gynecologist specializing in transgender surgery, reproductive endocrinology and infertility. "Dr. Gray met me with the biggest smile," Terrell says. "Her happiness and positivity are contagious. Her first question was just how far I wanted to go with my transition."

Dr. Vandergeest-Wallace notes that all transgender people have gender dysphoria, a diagnosis that is not classified as a mental illness but is marked by "a psychological identity as a man or woman that is not congruent with the biological sex at birth." But there is wide variability in how each individual feels about becoming physically comfortable in their body. Not every person wants the same series of procedures. Terrell, for instance, opted not to have bottom surgery, feeling it isn't crucial to his male self-image.

When talking with Dr. Gray, Terrell opted for hormone therapy, a hysterectomy and mastectomy. "I'd been binding my breasts since I was 18," he says. "I just wanted all the female parts to be removed. Dr. Gray helped me map out the journey, and Judy spent time going over what to expect from the hormone therapy."

In July 2016, Terrell began taking testosterone and soon noticed significant changes: his voice deepened, he began growing facial hair and his breasts became smaller.

Dr. Gray performed Terrell's hysterectomy in January 2017. He says Dr. Gray was dedicated to his care, even visiting him on the weekend in the hospital to ensure he was recovering well.

While the hysterectomy was a huge step, Terrell says "top surgery was everything. I'm finally able to look in the mirror and see who I really am." On June 11, 2018, Terrell had the mastectomy that finally allowed his physical body to match his self-image.

Terrell didn’t expect to cry when he saw his post-surgical body in the mirror for the first time, but the tears came as he realized he finally looked like the man he is. "I'm reborn,' he says, just days after his surgery. "I feel like who I am has really come to life. I can finally breathe."

Looking to the future

Terrell continues to follow up with his doctors at The University of Kansas Health System, yet he feels his ties there go deeper than just as a patient. "I almost feel like they're family," he says.

Now that his transition is complete, Terrell looks to a bright future. He continues to work in nursing while also establishing a commercial cleaning business with his son, now 20.

"College turned out not to be for him," Terrell says. "But I want to show him that it's possible to reinvent yourself. I think I'm showing him that with my whole life," he says.

Terrell's family is also expanding. He's engaged to be married, and he and his wife hope to have a baby. He's even reestablished ties with his parents, a process of communication and forgiveness on both sides of the relationship.

Terrell shares his story in the hope that other transgender people will recognize that making their own transition is possible and joyful.

"I want to be an advocate and help other transgender men, particularly men of color like myself," he says. "I think trans men like me can help fill a gap for those younger trans men who might be struggling."

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