‘Never ask permission’: How two trans women ran a legendary underground surgical clinic in a rural tractor barn

Somewhere in the boondocks of America's Pacific Northwest, near the city of Olympia in Washington state, there is a long gravel logging track leading off the main road between a field and a forest.

If you follow that track for about a kilometre, you will find a rustic-looking wooden house that has stood there for about a century, with an old tractor barn converted into a small outbuilding. There might be chickens, sheep, and geese honking raucously at your arrival.

And, if you had entered that tractor barn between 2004 and 2006, you would have found a secret underground transgender surgical clinic run by two trans women with an autoclave and a cauterisation machine bought on eBay.

In an era when trans people were routinely blocked from life-saving healthcare, and often discriminated against or abused by medical staff, this clinic aimed to treat its patients with respect and never charged more than $500 for a procedure that usually cost thousands.

Yet despite its clandestine nature, it operated legally – and according to one of the women behind it, it was even inspected and approved by Washington state health officials.

"No one was going to take care of us. We had to take care of ourselves," says Eilís Ní Fhlannagáin, a software developer and veteran protest medic who helped set up and run the clinic.

"We wanted to make sure that folks would never get a bill in their old name – simple things like that. They would be able to wake up and be surrounded by trans folks who knew how to take care of them, how to treat them. Never have to worry about getting misgendered. Never have to worry about 'what's your real name?' Never have to worry about any of that."

Now 50, Ní Fhlannagáin spoke to The Independent about her role in an almost forgotten moment in LGBT+ history, which until the pandemic had only been passed on through zines and word of mouth within the trans community.

This Pride Month, with transgender healthcare in the US and Europe under renewed political attack, she believes it still holds important lessons for both trans and non-trans people fighting for control over their bodies.

"We [can't be] sitting here looking for, 'oh, please, please give us things!' No, we're going to f***ing take them," says Ní Fhlannagáin.

"This is the thing folks don't realise about trans folks: if you make it so that I can't get access to the things I need to survive, I'm going to find a way to do it. We are a clever people. We will figure out a f***ing way to do it."

It started in Philadelphia in the early Noughties, when Ní Fhlannagáin persuaded her doctor friend Willow that she could totally perform life-changing surgery on Ní Fhlannagáin in her adopted trans mother's living room.

Ní Fhlannagáin grew up in a working-class Irish-American community in New Jersey, in an abusive household. "When I transitioned, I basically lost everything," she says. She dropped out of university after a year and taught herself to code, riding the dotcom bubble of the late 1990s.

Today she lives in Connacht in the Republic of Ireland, still coding and spinning yarns, voice gritty from smoking a pack of cigarettes a day. She rarely talked about the clinic until 2020, when she first told her story in a Twitter thread and on the podcast Totally Trans.

"I don't know, I always downplay this," she laughs now. "It embarrasses me when people go 'oh my God, you're so cool'... I don't trust role models. You put people up on pedestals, they're gonna fail you. I am imperfect, trust me."

When Ní Fhlannagáin transitioned, around 1993-4, most cisgender (or non-trans) people were barely aware trans people existed and would never expect to see one in real life. For those who lived openly, or were outed against their will, tremendous discrimination was the norm. Few countries had formal legal protections, and the world wide web had not yet given isolated trans people a lifeline to each other.

For trans women, the game plan was to get hormones any way you could, stay on them for a year or so without coming out, burn away your facial hair with electrolysis, then disappear from your old life and go "stealth" – meaning no one, except perhaps other trans people, knew you were trans.

"You came up through certain ways," Ní Fhlannagáin explains. "You came up through the clubs, came up through drag shows, you came up through the support groups – I kind of knew some of those folks – or you came up through gender clinics."

"I knew no one from there. That was the rich girl s***. Rich girls got sent to gender clinics; I didn't get into a gender clinic."

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The first step in a medical transition is usually gender-affirming hormone replacement therapy (HRT), which slowly reshapes a person's body and emotions by adjusting their balance of estrogen and testosterone. For many the impact is life-saving, not only making them happier with their appearance or more able to "pass" as a cis man or woman but connecting them to their body in a profound new way. Some compare it to seeing the world in colour for the first time, or coming up from underwater and breathing air.

Yet before Barack Obama's flagship Affordable Healthcare Act in 2010, few US health insurers covered such treatments, and in the Nineties few clinics even offered them. Hence, Ní Fhlannagáin says many trans people were forced into the care of "sketchy doctors" who often mistreated them.

"It was calling up the physician that got his licence taken away because he was prescribing one too many narcotics," she recalls. "It was online pharmacies, because online pharmacies became a thing. Or if you weren't online, that friend of yours who went to Mexico and brought back a suitcase."

This was the time of "Butcher Brown", alias John Ronald Brown, a San Francisco surgeon who specialised in trans women but was forced to set up shop in Mexico after his US medical licence was suspended. "The quality of his results was generally considered unacceptable," writes Andrea James on her widely consulted Transgender Map website.

In 1999 Brown was jailed for murder after one of his patients – a man who was psychologically fixated on amputation, and whose healthy leg Brown agreed to remove – died of gangrene.

Nor were you safe with above-board medics. In 1995, a Black trans woman named Tyra Hunter was injured in a car accident in Washington DC. When ambulance staff realised she was trans, they jumped back, stopped treating her, and stood there mocking her while she bled to death. A jury awarded her mother $2.9m; the city appealed, then settled for $1.75m.

"The medical profession is just flat out abusive to us," says Ní Fhlannagáin. "It has traumatised multiple generations of trans women. We don't go to doctors. My tit''ll be falling off, I'm not going to a f***ing doctor."

Indeed, her own trans mother – a mentor role common among trans people, who are often estranged from their birth parents – died of a stroke at the age of 62 after years of sickness because she did not trust doctors.

By the turn of the millennium, though, Ní Fhlannagáin was running in punk anarchist circles, absorbing riot grrrl feminism and radical environmentalism and transgender separatism. It was a scene that shaped a generation of North American trans women.

"We're not going to ask for permission for something that we should be able to just do," says Ní Fhlannagáin, summarising their attitude. "It's my f***ing body. If I want to go get my ears pierced, no one's going to say, 'oh, you can't do that, you need two letters from psychiatrists'."

All of which helps explain how Ní Fhlannagáin convinced Willow to perform an orchiectomy on her – that is, remove her testicles – in a reclining chair, working from photocopied pages of a medical textbook, while her trans mom was sleeping off her night shift upstairs.

The procedure almost went smoothly. But the instructions for bandaging afterwards were written for cis men, whose genitals function very differently than trans women's after a year or two on HRT. Six hours later the bandages fell apart, and Ní Fhlannagáin was rushed to hospital. On her first try, she was thrown out for "drug-seeking behaviour" ("yeah," she recalls, "I needed antibiotics"), and only got treatment days later after nearly dying.

This experience evidently did not deter Willow, because afterwards – when both women coincidentally found themselves living in Washington state – she made a proposal to Ní Fhlannagáin: why not start their own orchiectomy clinic?

"Overall the DIY orch is very simple and teachable," wrote the trans novelist Sybil Lamb in 2010. Sure enough, orchiectomies – under the more traditional name of castration – were performed without modern surgical equipment or anaesthetic around the world for millennia, with all manner of religious and political purposes.

For trans women, an “orchi” can relieve gender dysphoria and allow them to stop taking testosterone blocking drugs, which often come with unpleasant side effects.

"It's just not a complicated surgery – mine took like 40 minutes," says Jules Gill-Peterson, a professor at Johns Hopkins University who is writing a book about the history of DIY trans medicine. Her research has found evidence of underground trans orchis going back to the 1950s, as well as hormone sharing and smuggling, making the Washington clinic part of a “hallowed tradition”.

"It's really slow-going research, because you find these little pockets –this group of people did it for this short amount of time,” Gill-Peterson says. “It tends to be people with fewer resources, who are poor and aren't going to be leaving behind records… but there is this interesting history of trans women figuring out how to do the one surgical procedure that you could reasonably do without going to a surgeon."

There are even stories from the Fifties of people asking doctors how to do it, under the guise of curiosity, and doctors explaining and then knowingly leaving the room so they could help themselves to spare medical supplies.

Willow was not only a doctor but, rarely for the time, an out trans woman. Ní Fhlannagáin declined to provide Willow's real name because she now works as an abortion doctor facing threats of violence, and told The Independent that Willow does not wish to speak to journalists.

By 2004, Ní Fhlannagáin had burned out on anarchist activism and moved to Washington with her girlfriend Chrissy, where Willow was doing a residency. Ní Fhlannagáin needed money, and Willow had an "eBay addiction" where she would buy old medical equipment and fix it up. They hatched a plan.

"I don't want this to come off as like, there was this mission," says Ní Fhlannagáin. "People get this idea that I was anything other than a low bagger who needed to make money... we were dumb punk kids, man!"

Still, both women had been involved in abortion activism, and they drew political inspiration from an underground women's abortion service called the Jane Collective. Operating in Chicago between 1969 and 1973, it was founded as an antidote to unsafe illegal abortions often done by unqualified men.

While the Jane women’s actions were criminal at the time, legal compliance for a rural orchi clinic turned out to be surprisingly simple.

"What's a doctor's clinic?" asks Ní Fhlannagáin. "A doctor's clinic is a clean room that's up to a certain standard, with clean instrumentation that's up to a certain standard, that has records up to a certain standard, drug supplies and how it's stored up to a certain standard, and a licensed doctor and all your taxes and your business stuff up to a certain standard.

"We just met those standards, and the standards are not difficult to meet... we've just grown up with western medicine and basically surrendered ourselves to their whims."

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Although they couldn't afford medical malpractice insurance, they also wouldn't make enough to need a business licence, and nor would they store opiates or narcotics on site. Ní Fhlannagáin went through medical privacy law training and put out the word.

They didn't tell the neighbours, nor the landlord. Nobody out there knew that Willow, Ní Fhlannagáin, or Chrissy were trans – rural women weren't expected to be feminine in the same way as city women – and they intended to keep it that way.

One week before the first surgery, on the 256-acre farm that Ní Fhlannagáin and Chrissy were renting, they built a front and sides onto one of the bays in the tractor barn; put in a door and a window, ran in electricity, and tiled and sealed the floor.

That tiling, Ní Fhlannagáin adds, is still there today, though the room is now used as an organic chicken processing factory. "They still don't know what I did in that room," she says, "which I plan on never f***ing telling them, ever."

If, one day in 2005, you had driven down that logging road for your appointment at the clinic, the geese would have heralded your arrival.

The room inside the tractor barn would be about eight by twelve feet. As you walk in, there'd be a chair and a coat rack on your right, a locked cabinet on your left ("Willow built [it] herself, so it was of course overbuilt," recalls Ní Fhlannagáin).

Beyond is a long desk with an autoclave – a specialised furnace for sterilising medical tools – and an electric cautery machine. In the middle of the room is a chair with stirrups, where the patient sits.

The two women explain what will happen and how it will work. You get a prescription for vicodin and pre-emptive antibiotics, which you have to fill at the nearest town 20 miles away. You take the vicodin in front of the medics, and then begin the surgery.

Ní Fhlannagáin's job in all of this was basically to tell "really bad dad jokes", talking in a low, rhythmic, faintly hypnotic voice. For instance: two mushrooms walk into a bar. The bartender says they can't be in here. One mushroom says, "why? I'm a fun guy.”

"See, you chuckled but you didn't laugh," says Ní Fhlannagáin after the punchline. "Laughing while we're working down there is bad. Doing a 'heh' is good. It means you're paying attention to something else."

Afterwards, they'd apply tight bandages and drainage tubes, following new procedure designed specifically for trans women after Ní Fhlannagáin's near-death experience. You were required to stay in the area for seven days in case of complications, but Ní Fhlannagáin says they never had one. Most people simply crashed on her couch.

The clinic charged a sliding scale, depending on circumstances, never charging more than $500. For another $400, you also got 40 hours of electrolysis, which Ní Fhlannagáin had learned by practising on her own arm.

The amount was based on the cost of materials and the minimum amount needed to pay for Ní Fhlannagáin's daily Amy's Mac and Cheese and tobacco bought in bulk. Usually, an orchi alone would cost $2,000 to $5,000 – about $3,000 to $7,500 in today's money.

The clinic also catered to people who had HIV, who Ní Fhlannagáin says many doctors at the time refuse to treat. "We did surgeries for folks that no one would touch," says Ní Fhlannagáin. "The only good thing that I took from Catholicism was that you're judged by how you treat the least among you. And we were dealing with people who were in the same boat as us."

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However, patients did have to get a letter from a social worker or other authority figure testifying that they were trans and needed the surgery. Ní Fhlannagáin didn't like that, but says it was necessary to protect the clinic from lawsuits or government investigations.

The policy meant sometimes having to turn down patients who had their documents in different names and couldn't show a link between them, or being more cautious about non-binary patients whose situation was complex.

It also meant they had to ask for patients' old names – often called "deadnames" in the trans community, and generally taboo unless absolutely necessary – if they hadn't been able to navigate the bureaucracy to get a legal name change. For Ní Fhlannagáin, who opposed the intrusive and sometimes prurient psychological interrogations that had traditionally regulated access to trans healthcare, it was a painful situation.

""We had to make some really f***ed up, tough calls," says Ní Fhlannagáin. "I have no training in this, and I have to evaluate, 'is this person trans'? I shouldn't have to do that, but the system is set up such that I need to... we weren't given a choice."

Then there were the occasional weirdos, like the man who emailed the clinic claiming he had cheated with his brother's wife and needed to be castrated urgently (Ní Fhlannagáin did not respond). There was also culture clash between the medics and some patients, including one woman who filmed the experience for an artwork.

One time, the landlord unexpectedly came by to paint the house while a girl was having surgery. Ní Fhlannagáin asked her girlfriend to keep him occupied and locked the door. "My guess is, he thought we were doing porn," she says. Largely, neighbours left them; rural people didn't poke too much into each other's business.

After your surgery, if you wanted, Ní Fhlannagáin and Willow would take you further up the logging road, set up some cans, and teach you how to load, aim and fire an AR-15.

One day, while Ní Fhlannagáin was drinking her first cup of coffee, the geese began honking because a big dark blue car with government plates was coming down the track.

In the wake of the huge protests at the World Trade Organisation conference in 1999, and the shadow of 9/11, many of her peers in the anarchist movement had received visits from law enforcement. But these people didn't look like cops; they looked like bureaucrats.

The officials said they were from the state Board of Health, and they were looking for Willow. Ní Fhlannagáin sent her a pager message saying "911" – meaning 'call me right away' – and waited. Then paged, then waited, then paged.

"Finally she calls, and she's like 'this better be good, I'm at work'," recalls Ní Fhlannagáin. "I'm like, 'well, the Board of Health is here and they would like to see the surgery'. [She says,] 'stop f***ing around! What is it?' [I say,] 'well, the Board of Health is here...'"

Ní Fhlannagáin says she would later trace this visit to one of her stranger patients. Although she and Willow would always advise patients to come in practical clothes and shoes for the gravel and dirt, this woman – “let’s call her Julie”, says Ní Fhlannagáin – turned up in a mini-skirt and four-inch heels.

After the procedure, Julie asked when her voice was going to get higher. Ní Fhlannagáin explained, as she had beforehand, that orchis don't change your voice and she would need to practise like any other girl. Julie was also dissatisfied with the stumps of skin left by the surgery, though Ní Fhlannagáin says this too had been explained in advance.

The whole affair made them tighten their patient checks, but in the meantime Julie later went to her GP and explained her situation. "[The GP] says, 'this is really well done work. Who did it?'" recounts Ní Fhlannagáin.

"Now, while entirely true, what she said absolutely positively misrepresented what the situation was. She said: 'two trans girls up a logging road in a barn'." The GP duly called the authorities.

Ní Fhlannagáin remembers telling the bureaucrats to wipe their feet. They didn't, and tracked mud into the clinic. They asked to see autoclave logs, business licences, narcotics stores, all of which Ní Fhlannagáin was prepared for. Then she spotted something catastrophic: a little cup, with two testicles in it, left just behind the cautery machine.

Normally, patients were supposed to bring their balls with them after surgery. But Dana, last night’s patient, was "an absolute lightweight" and was zonked out on vicodin. Ní Fhlannagáin and Willow had to haul her into the house, then give the clinic a quick wipe down and focus on looking after her, intending to clean up fully tomorrow. (Ní Fhlannagáin asked Dana’s permission to tell The Independent her name.)

Luckily for Ní Fhlannagáin, she had learned a "cheat code" for situations like this. "When a cis bureaucrat is getting in your face, and you want them to disappear, say the words 'transgender' and 'transsexual' as loud as possible and as many times as possible," she says. "They get very uncomfortable and they back away."

The clinic had been trying to get Medicaid coverage for another trans girl, so Ní Fhlannagáin began loudly berating the officials for their agency's obstruction. "I just start going off, and the entire time I'm going off I'm thinking 'please don't look behind the electrocautery'."

They scrammed, allowing Ní Fhlannagáin to grab the organs, stick them in her pocket, dart into the house, and tell her patient: "Dana, you left these."

Four or five months later, the Board of Health passed its judgement. Ní Fhlannagáin says it gave the clinic an almost clean bill of health, but rapped it for the mud on the floor – which Willow still has to explain today.

"Twenty years later, I'm still mad about that," says Ní Fhlannagáin. "I'm like, you guys literally didn't wipe your feet like I told you."

Ní Fhlannagáin says that the clinic ultimately treated 14-16 patients, with no infections or complications. Each one signed the door jamb, which Willow took away and then lost.

The Independent was not able to speak to any patients, and privacy law prevents Ní Fhlannagáin from revealing their identities without their permission.

She is proud of the work she did, saying: "I don't regret helping a bunch of girls that wouldn't have been helped." But the clinic did not last long. In 2006, Willow's residency ended, taking her out of the Pacific Northwest, while Ní Fhlannagáin herself was burned out.

"Trans healthcare is a drag," she says. "I f***ing hate doing trans healthcare. I'd never do it again. It's one of the most rewarding things and one of the worst things that I ever had to do.

"Part of that is that you were seeing folks at their most vulnerable. And trans girls? A lot of the time we don't do vulnerable real well. Because if you do vulnerable a lot, you don't last long. Anyone who does trans healthcare, God bless 'em. God bless 'em."

Worse, Chrissy was suffering from slowly worsening mental health problems, including alcohol and substance abuse, leaving Ní Fhlannagáin straining to keep her away from patients as much as possible. About three years after the clinic closed, they broke up, and four years after that, Chrissy killed herself.

"It's the same story, right?" says Ní Fhlannagáin. "This is a world not built for us. And how do you live in it? It's 35 people now, queer folks, and about two thirds of them trans, that I've lost over the years."

They did their last surgery three days before the clinic shut down. Willow and Ní Fhlannagáin went their separate ways, and largely kept quiet about the experience. Then something strange started to happen.

Ní Fhlannagáin's Irish friend Nóirín, who had been in Germany when the clinic was operating, told her they’d heard about it through a friend. Sybil Lamb described it in her essay about orchis, though she changed some of the details. The legend of the "ball barn", as some dubbed it, was spreading through the global trans community by word of mouth.

"Absolutely – I've heard of it several times from different people," says Gill-Peterson. "Especially other trans women, in the kind of conversations we have with one another, where we're talking about what we really know, and how our lives really are... it's like the trans version of six degrees of separation."

Trans history, she argues, has been "over-narrated" by medical institutions, which often defined mainstream discussion about trans people from within its own narrow worldview. She believes that researching and remembering DIY healthcare can challenge that, restoring the diversity of the many trans communities – from "black and brown trans-fems who came up through the ballroom scene" to mostly white punks in the Pacific Northwest – that have carried knowledge through the generations.

The story also reached Nicki Green, an internationally exhibited sculptor and lecturer in ceramics at the University of California, Berkeley. She contacted Ní Fhlannagáin and gained information about the clinic, making an artwork about it called Operating in Bright Sunlight, featuring paintings of the old farmhouse, the trees, and the procedure itself.

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"I think I was particularly excited by the idea of not having much information, or the information I had being all word of mouth. There's something that feels very fluid, very trans about that way of working," Green tells The Independent.

"The spread of info as it becomes mythologised, evolves and changes... feels subversive and mirroring the finding and accumulating of info that was so central to my experience of coming into my transness."

But, she adds, she was also excited about being able to record this "amazing" piece of history in a more durable way. "Fired ceramic is a permanent material, so recording history on ceramic forms allows for a means of archiving that is very physical, material and elemental," she says.

"[It's] immortalising a history that feels very significant to the evolution of trans care and particularly trans women supporting each other."

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Today, Republican politicians in states across the US are seeking to ban or restrict access to transition healthcare for trans children, while stoking panic and revulsion about trans people in general. Some GOP politicians have signalled that adult transition care could be next.

In the UK, gender critical feminists have also campaigned to ban all trans healthcare for under-18s and are increasingly arguing for restrictions on adult care. The activist group Transgender Trend has said transition care for adults under 25 is “the next big scandal”, while Kathleen Stock, a leading gender critical thinker who was awarded the Order of the British Empire last year, told the Spanish newspaper El Mundo that “if it were up to me, no one should undergo a sex change until they are 25”.

In fact, waiting lists for NHS gender clinics in Great Britain now range from around seven months to nearly six years for a first appointment, according to volunteer reports (two appointments are needed before HRT can be prescribed). London’s gender clinic is seeing people who were first referred in January 2018. Although Ireland’s waiting lists are officially around 2-3 years, FOI requests from a trans rights non-profit reportedly suggests some people could wait nearly a decade.

Meanwhile, the US Supreme Court has revoked the nationwide right to abortion after nearly 50 years, causing abortions to instantly become illegal in states with so-called "trigger laws" on the books, with other states likely to follow.

To Ní Fhlannagáin, this shows that the days of Butcher Brown are not just history – and makes the clinic's relevance crystal clear.

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"Abortion issues and trans healthcare issues, they're the exact same fight," she says. "It's, do people have the right to do with their bodies as they see fit? Does the government have the right to tell medical providers what they can or can't do to a person who has given informed consent?"

She believes that cis LGB people who win their civil rights, as well as trans people who achieve healthcare and security, must not "pull up the ladder" behind them as some in her generation did – not least because what they have can still be taken away.

"Working on trans healthcare is working on cis people's healthcare," she says. "How many cis women have come to me and said, 'oh, I'm starting to hit menopause, the doctor doesn't want to give me [HRT]'. All right, honey, here's what you do."

The next Jane-like group, she adds, may be spreading insulin – a drug that people with diabetes cannot live without, priced so high in America's broken healthcare market that people die because they can't afford it.

Beyond that, she hopes that telling her story will weave ties between younger and older LGBT+ people, helping the former see that they are not alone and that they have models to draw from.

She describes how, on the back of the clinic door, there was a quote from Jean Liedloff's book The Continuum Concept, based on its author's time among the indigenous Yequana people of Venezuela.

“A sure sign that something is seriously missing in a society is a generation gap. If the younger generation does not take pride in becoming like its elders, then the society has lost its own continuum, its own stability, and probably does not have a culture worth calling one..."

Ní Fhlannagáin believes that applies to trans people too. "I'm 50 and an 'elder'. How the f*** does that happen? Well, because the previous generation, a lot of them died – in the Aids crisis, or for the many, many reasons we died early – and no one gave a s*** except us. Or you went stealth, and you never, ever, ever, ever, ever, ever talked about it.

"That's by design. If you don't have continuity of culture, you have no ability to stand up and say, 'this is wrong, stop treating me like s***'. So how do you unf*** a people? How do you create a culture of resistance?"

To younger trans people seeking that goal, she offers this advice: "Don't ask permission for how you live your life... what are they going to do, get you in more trouble? You're trans, honey; you're already in trouble. Just don't get caught."

The Independent is the official publishing partner of Pride in London 2022 and a proud sponsor of NYC Pride.