FARGO – Brianna Cassady said she was 8 or 9 years old, growing up in a small town in Iowa, when she realized that despite her outward appearance as a boy, she was “a little girl.”

She continued to dress in a masculine way for years, she said, because she didn’t want people to make fun of her.

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In her late 20s, however, the transgender woman decided to embrace her true self and begin a gender transition. Now 33, she recently completed the final step in doing so.

On Friday, June 15, Cassady underwent full gender reassignment surgery. Her surgeon believes it was the first time the procedure was done in North Dakota.

“As far as I know, I am the first,” she said.

The surgery is known as transgender vaginoplasty, in which the scrotum and testes are removed and skin from the penis is inverted to create a vagina.

“If you have the right surgeon, it looks really nice,” Cassady said, adding, “Mine does.”

The six-hour surgery was done by Dr. Ahmed Abdullah of the Plastic Surgery Institute in Fargo.

He assembled a surgical team at Essentia Health, one of two hospitals at which he has practicing privileges.

A spokesperson at Sanford Health in Fargo said the facility offers hormone treatments that precede gender reassignment surgery, but when it comes to the surgery itself, Sanford does “top half” procedures only.

Other hospitals in the state also said they don’t do gender reassignment surgery.

“We should really be proud of being able to do this in Fargo, when some of the bigger places are still struggling with having this service available,” Abdullah said.

Cassady said some transgender women opt to keep their male anatomy; others like herself want to make the full transition but can’t afford it.

However, some insurance companies, including Blue Cross Blue Shield of North Dakota, have begun covering gender reassignment surgery.

Abdullah said the requirements for coverage are strict. Patients must be diagnosed with gender dysphoria or transgenderism, a condition in which a person feels a strong, persistent identification with the opposite gender.

“I think these people are born in the wrong body,” he said.

At first, Cassady was only considering breast implants, but changed her mind after learning Abdullah also did the bottom half surgery.

The female hormones she was taking as part of the transition process helped fill out her breasts, and changed her views of sexual attraction.

“After starting the hormones, I became to liking men and I just wanted to feel complete as the woman that I was,” Cassady said.

She expects to be away from her job as an over-the-road truck driver for about a month, as she recovers.

Before moving to Fargo in the early 1990s, Abdullah did hundreds of gender reassignment surgeries during his residency in Galveston, Texas. He studied under the late Dr. Ted T. Huang, the man who he said pioneered the procedure.

“In fact, one of our patients ended up being the centerfold in Penthouse magazine,” Abdullah said.

Gender reassignment surgery isn’t cosmetic or reconstructive, but more like reorganization and, someday, could be done as an outpatient procedure, he said.

The surgical transition can be male to female or female to male, but the first is much more common and successful.

“Male to female functionality is incredibly unreal. In six months, you can’t tell this person was male,” Abdullah said.

Transgender people are at higher risk for suicide than the general population, and gender reassignment surgery can markedly improve their mental state, he said.

Still, it’s a huge step.

As Abdullah tells all of his plastic surgery patients, it’s a one-way street.

“Once you go this way, there’s no going back and this is probably the ultimate of that,” he said, referring to gender reassignment.

Those patients tend to be some of the most satisfied, though, because they’ve become the person they see, not the one society assigns.

“You changed their life,” he said.