An hour later, as Nicole was filling in an evaluation form, she turned to Rey and said, "I hate this question: 'What is your gender?' "
"Me too," Rey responded. "I'm just a guy."
"And I'm just a girl," Nicole said.
Both revealed then that they were transgender.
Nicole, 36 and Rey, 45, (their full names are being withheld for privacy and because of their fear of workplace discrimination and violence against trans people) enter the Bala Cynwyd office of surgeon Sherman Leis, holding hands and laughing. The happy pair looks like any couple in love. They are there for their checkups and to talk about the inevitability of their relationship and how they ended up with the same doctor a three-hour drive from their homes in the Washington, D.C., area.
"Over dinner, two days after we met, we had an intense conversation couples don't usually have on a first date," Rey recalls. "We talked about our values, the qualities that make people compatible, our painful childhoods, and where we are now."
Nicole told Rey that she had already completed her full transition, which had begun three years earlier with taking female hormones and banishing body and facial hair through long, grueling sessions with an electrologist. In November 2011, she had had surgery to feminize her facial features and an orchiectomy to remove her testicles. A year later, gender reassignment surgery gave her a vagina.
Rey confided that while he had been administering testosterone topically since he was 39 and had a double mastectomy with chest reconstruction, he had finally decided to go all the way with "bottom surgery" - genital reconstruction that creates an adult-size penis and repositions the clitoris to preserve erotic sensation and orgasm. The couple thought it was destiny that Rey had already settled on, through word-of-mouth suggestions, the same Philadelphia surgeon that had performed Nicole's operations.
No one knows for sure how many transgender people there are in this country. Gary Gates, a demographer at UCLA's Williams Institute, a national think tank for research on gender identity, estimates about 700,000 adults.
Add to that a growing number of adolescents and children who insist they have been born into the wrong bodies. An annual survey from the Gay, Lesbian & Straight Education Network found that 8.3 percent of LGBT youth identified as transgender in 2011, up from 3.2 percent in 2001. Norman P. Spack, head of the transgender clinic at Boston Children's Hospital, the first of its kind in the country, suggests that one in 1,000 children and adolescents may be transgender.
Because of the growing need, Children's Hospital of Philadelphia in January established a Gender & Sexuality Development Clinic to serve transgender and gender-nonconforming children and adolescents from three to 21 and their families. Twenty have already been seen.
Nicole and Rey didn't have the language to express their feelings until they became adults, but both say they knew from the time they were toddlers that they had been born into bodies that betrayed them.
"I was too young to understand gender and sexuality, but I knew I was not a little girl," Rey says. "My mom would make me wear a dress to church on Sunday, but when we left the service to go to lunch, I would throw a tantrum because I refused to go to a restaurant in a dress. Finally, my parents gave up and would take me home so I could change into my boy clothes."
When he was 18, Rey told his parents he was a lesbian. He knew he was attracted to girls and didn't know what else to call himself. His distraught parents sent him to a psychologist.
Nicole, meanwhile, spent her childhood brooding because she couldn't wear a pink dress like her younger sister. "Inherently, I felt like a girl and I couldn't wait to dress up in my mom's or sister's clothes," she says. "At school, I would hang out with the boys. I wanted to fit in, but I kept looking at what the girls were doing and wished I were there. I never told my parents because I was embarrassed."
When Nicole reached puberty, she tried to disguise the changes in her body. She started shaving her face every day and was terrified that her body would keep sabotaging her. Her life became agony and by the time she was 32, she had decided to commit suicide. "Either I transitioned physically or I couldn't live," she says.
Sherman Leis performed his first transgender surgery in 1975 at Springfield Hospital in Delaware County - a female transitioning to male. Despite the operation's success, there was little demand for it, and Leis continued to focus on cosmetic and reconstructive procedures.
But ten years ago, his interest was rekindled, and today he is considered one of the country's premier specialists in transgender surgery. Since opening his Bala Cynwyd Center for Transgender Surgery in 2004, he has performed more than 3,500 operations on transgender patients, including facial feminization procedures, breast removal or augmentation, and sex reassignment surgeries. His patients have ranged in age from 17 to 80.
In addition to the obvious breast enlargement and genital changes sought by a male who is transitioning to female, she may want any combination of the procedures to the face that can create a softer, more feminine appearance - fuller lips, a more delicate nose, a narrower chin, a lower frontal hairline. Reduction of the Adam's apple is almost mandatory; leaving it alone would be a giveaway that she was not born a woman. Lana Moraes, 24, a North Jersey woman, says her voice is still a little raspy, but that she is recovering well from this operation, which Leis performed last month.
Leis performs more male-to-female "bottom surgery" than the other way around, not because there are more men wanting to transition, but because the surgery is more effective functionally and cosmetically. "I can create female genitalia that looks like and functions close to 100 percent like a female," Leis says. "With men, I can create an acceptable cosmetic appearance of male genitalia, but not a functional penis that can have a natural erection. We teach patients about external means of support to make the penis firm enough for intercourse, and the way we transpose and place the clitoris makes it a highly erotic area when stimulated by intercourse or touch."
While recovery time varies, most patients can return to work in four to six weeks after this kind of surgery, and can be exercising two months later, Leis says.
"All my life, I was terrified of any kind of operation - tonsils, even getting wisdom teeth out," Nicole admits, "but I couldn't wait to have this one. I was smiling going in and I was smiling going out." An unexpected bonus was that Nicole's mother, who for three decades had been in denial, insisted on accompanying her to Bala Cynwyd for her surgery.
"When it was over, the biggest change for me was emotional," Nicole says. "Before the surgery, I didn't really have feelings. I was flat and I thought flat was normal. Afterward, I became alive emotionally. It had been 14 years since my younger brother had died, and I hadn't been able to mourn for him. Now, finally, I could cry."
Like Nicole, Rey had been struggling for decades with his gender identity. Through his 20s and 30s, as the lesbian he thought he was, he dated women. "But I always knew that I wasn't a woman," he says, "and I didn't know exactly where that left me. By the time I was 38, I knew I couldn't go on that way."
Rey's family didn't understand; his sister couldn't imagine exchanging a sister for a brother. His parents were distraught, especially his father. "But he bounced back amazingly quickly," Rey says, "and I could see the beginning of a better relationship with him." Three weeks after his father started using the correct pronoun, calling Rey "him," he was killed in an automobile accident. The relationship with his mother was strained, but when Rey told her he was coming to Philadelphia for surgery and wanted her by his side, she didn't hesitate.
Since that time, she has embraced having a son. "You don't know how powerful it was on my 42d birthday to get a card from my mom that said, 'Happy birthday, son.' It brought tears to my eyes."
Nicole and Rey's story is unusual, but there is growing acceptance of people like them. "There has been a shift in the way we think of trans people," says Jennifer Finney Boylan, an author who for 25 years was an English professor at Colby College in Maine. Last month, she joined the faculty at Barnard College as the inaugural Anna Quindlen writer-in-residence.
"Those of us who are trans and out and in the public eye are determining how our lives should be discussed as opposed to sensationalizing our experiences," she says. Boylan, who was born in Newtown Square and raised in Devon, transitioned in 2001 after she was married and had fathered two sons. "I've been on dozens of television shows - and I almost never left one without being on the verge of tears," she says. "I was treated like some alien who had landed here from Mars. It was left up to me to justify my existence and explain how it was that I could possibly be human." Boylan's most recent book is a memoir, Stuck in the Middle With You.
"We have to listen to what the children tell us," says Spack, who is associate clinical professor of pediatrics at Harvard Medical School. The four-year-old who insists that God made a mistake, the five-year-old boy who says, "If you don't let me be a girl, I'll kill myself," are not mentally ill, he says. "It has something to do with the wiring in the brain - maybe a gene that is expressed at a certain stage of fetal development or hormones gone awry during gestation."
It has nothing to do with being gay or lesbian or wanting to be a cross-dresser, Spack said.
"I went through transition," says Boylan, "not because I wanted to wear high heels and sequins, but because I wanted a body that would fit this brain, this heart, this life."
"You know how desperate I had to be to go through the surgery I had," says Rey. "I can't think of anyone who would put himself through that if he could survive in the gender he had been given. I had no choice."
"For me, the surgery was the easiest part," Nicole says. "Before transitioning, I hated everything about myself - my voice, every hair that grew on my body," She grimaces in recollection as she slides her index finger over the now-satiny skin of her cheek. It is an ongoing process. Besides the hormones that will be her companion forever, she continues to see her electrologist and still does voice therapy to gain mastery over the inflections, the pitch, the volume that distinguish female voices from male. And she still is learning how to behave like a woman - how to walk, how to stand, how to eat. "The body language is so different," she says.
But there are no regrets. "When I transitioned, I was prepared to lose everything - my family, my friends - and possibly have to spend the rest of my life alone. Who, I thought, would want to date anyone like me?
"As it turned out, I didn't lose anyone. I gained so much more because I'm living an authentic life. I am who I was meant to be."
Transgender surgery is expensive, and not usually covered by insurance. But times are changing. Several groups, including the American Psychological Association, have urged insurers to cover gender transition treatments when professional evaluations deem them medically necessary. More than 50 colleges and universities - including the University of Pennsylvania and Penn State University - include transgender people in their student health coverage plans.
Surgeon Sherman Leis charges about $20,000 for sex reassignment surgery and $8,000 for breast augmentation. Facial feminization costs vary by procedure: a forehead and brow lift is $4,500; rhinoplasty, $5,000; lip shortening, $3,000. Operating room and anesthesia are additional. Surgery that takes less than four hours can be done in an outpatient surgical facility; if it's longer, Leis takes his patients to Lower Bucks Hospital. Patients have to have been given hormones and lived as the opposite gender for a year before sex reassignment surgery, and two letters from mental health specialists trained in gender identity issues are required.