Hayley Anthony is a transgender woman who helped design a new surgical technique for male to female gender affirmation surgery.

Dr. Jess Ting is director of surgery at the Center for Transgender Medicine and Surgery at Mount Sinai in New York City.

Important information I do not have available is the names of the doctors in India who actually made the medical advance. Anthony discovered a paper on their research somewhere on the web and shared it with Dr. Ting.

Anthony had known her whole life that she was female, but she didn’t begin transitioning until about four years ago. Then, in the fall of 2015, after months of working with a therapist to better understand herself and her options, she accepted that she had to do whatever it took to have the right body for her mind. She scheduled a consultation with Ting and they made a date to make her a new vagina. Then she went home and down a deep internet hole. “I had gone into the process, eyes wide open, understanding all the compromises and willing to accept them,” Anthony says. The procedure she was mentally preparing for involved slicing open the penis, removing most of the inside parts, and then folding the penile skin into the space between the urethra and the rectum (kind of like turning a sock inside out). In what has become the standard surgery for a male to female bottom transition, the outside of the penis then becomes the inside of the vagina.

But a vaginal cavity made out of skin doesn’t do some things the inside of vagina should (like get wet when aroused) and does others it really shouldn’t (like grow hair, even after electrolysis). For trans women with genital dysphoria, it’s been the only real option for bottom surgery, and it’s been a pretty good one. But the procedure can still leave many disappointed.

The Indian doctors have been been building vaginas using tissue from the peritoneum, the tissue that holds your internal organs in place.

I kept thinking, there’s got to be something better,” he says. “But where were we going to find a large amount of pink, hairless, inner skin that secretes fluid?

--Dr. Ting

Dr. Ting was even more impressed when he discovered that the peritoneum repairs itself when injured in a matter of days.

In July, Mount Sinai launched the country’s first medical fellowship dedicated explicitly to transgender surgery. Ting will be training one fellow each year and he’s hopeful they’ll stay on staff once they’re done to help meet the city’s growing demand. Another important part of their job will be to follow up with these surgery patients over the next few years; while the new procedure is showing superior results so far, it will be important to monitor to see how it holds up long term.

In May, Health and Human Services Secretary Tom Price told a federal court that he’s reworking a provision in the Affordable Care Act that requires states to cover transgender care through their Medicaid programs. The rewrite is likely to free states to refuse coverage for hormones, counseling, and surgeries for transgender men and women. Not that they have to wait; Price said he’s declining to enforce the rule in the meantime.

Patients that live in left-leaning states that have passed their own protections for trans health care, like New York and California, will have a better chance of retaining access. About 70 percent of the transgender patients at Mount Sinai have insurance through the state’s Medicaid program. But many still have to fight to get the coverage they need. For those living in other parts of the country, the situation is even more dire. “There are few populations for whom if you started to play games with people’s access to health care it would be more detrimental.” says Anthony. “Trans people’s attachments to stable sources of income and legal protections are as precarious as they come. The progress we have made has been very limited, very contingent, and very easily lost.”