BOSTON – Evan “EJ” Silverberg sat on a gurney in the early-morning hours at Beth Israel Deaconess Medical Center.

He was uncharacteristically quiet and calm, a fact that concerned his girlfriend, Gabi Depari. She sat next to him and held his hand, smiling.

As hospital staff entered the pre-op room, excitement began to build. Ms. Depari, 22, chatted with staff. Registered nurse Jane Noonan read through the rundown of the day and talked with Mr. Silverberg, 27, about the IV in his right arm.

“It’s like Gatorade without the sugar,” she told him warmly.

Several more people in scrubs stopped in to take notes, update charts and check their patient’s vitals. Mr. Silverberg nodded his head and hardly spoke.

When Dr. Adam M. Tobias arrived, he asked everyone to clear out. The plastic and reconstructive surgeon gently tied Mr. Silverberg’s hospital gown to the waist, to give him some more privacy.

With an orange pen in hand, Dr. Tobias carefully marked points of incision across Mr. Silverberg’s chest, avoiding a textual tattoo on the rib cage. Mr. Silverberg extended his arms and tilted his head back slightly, his light blond hair shaved into the "David Beckham” coif shifting to the side. It’s the hairstyle that fits him best - a look he found years ago at an LGBTQ-friendly barbershop in Worcester.

Mr. Silverberg would later explain he felt an overwhelming level of anxiousness.

"Let's just do this already," he thought. "I'm ready."

Discovering identity

The Telegram & Gazette first interviewed Mr. Silverberg almost two years ago for a story about his gender-neutral clothing line, Sterling Royal. At the time, he went by his birth name, Elizabeth J. Silverberg.

About a year ago, Mr. Silverberg, a Shrewsbury native and graduate of Notre Dame Academy in Worcester, realized that he wasn’t an androgynous lesbian. He discovered he identified as a transgender man and began taking physical steps to transform himself.

Last month, Mr. Silverberg crossed a hurdle in matching his gender identity to the true self he said he knew was always inside of him, even since he was a child.

The only way he could feel comfortable in his own skin, he said, was to undergo a “top surgery,” otherwise known as breast reconstruction surgery, to remove his breasts. Though not all transgender individuals opt for medical procedures or physical changes to express their gender identities, this was Mr. Silverberg’s chosen path.

“I think for a lot of people, the scars are the lesser of two evils,” he said. “I can have scars when I go to the beach, or wear a shirt forever and hate myself.”

An internal conflict

Before the surgery, Mr. Silverberg bound his chest to feel more at ease physically, though the tightness underneath was excruciating. He described the feeling of the strong binding as suffocating, comparable to the pressure of wearing several exercise bras at once.

Top surgery became his only option, he said.

Mr. Silverberg decided to pursue the procedure after he was diagnosed by a therapist with gender dysphoria, the medical term for a conflict between someone's sex assigned at birth and their gender identity.

Mr. Silverberg said he wished to share his transition publicly because he wants others to know his experience, and hopes his story can help others.

“People (in the community) are sharing their stories on Instagram, on Snapchat and other social media,” he said. “... You wouldn’t want to go ask a doctor these questions, but because you can look online and read about it, and you know how you want things to go, it makes things easier.”

Breast reconstruction for transgender men, typically a three- to four-hour procedure, is the same procedure used to treat cisgender women diagnosed with breast cancer, Dr. Tobias said. Cisgender refers to people who are not transgender.

Mr. Silverberg said to align his body with his gender identity, his surgeon would have to work to define his pectorals and to hide scars from his incisions into the definitions of his newly shaped chest.

Last summer, when he first made the decision to pursue a physical transition, Mr. Silverberg began injecting testosterone into his leg with a long needle every two weeks.

Though he’s too blonde to grow in facial hair, Mr. Silverberg said since then his voice has dropped, his DD-sized breasts went down a cup size and his overall body shape changed for the better.

This transition now affords him the right to feel safe in public spaces. He recalled when he worked at the Millbury Nordstrom Rack in loss prevention, he would use the women’s room and get nasty looks from customers. The experience was so disturbing, he said he would watch on hallway surveillance cameras to be sure no one had entered the bathroom, and then rush in.

“(Your surgeon) gets to help you,” Mr. Silverberg said, reflecting on his experiences with his medical team. “Basically, as a surgeon, you’re granting me my new life. You’re handing me the keys to my new home and saying, ‘Here you go.’ ”

Changing a life in one morning

Mr. Silverberg’s 3½-hour surgery on July 15 went smoothly. He was discharged the same day. The total recovery period for Mr. Silverberg should take between four and six weeks.

Ms. Depari, his partner of roughly five years, was at his side, along with a transgender man who asked not to be identified for fear of outing himself.

Dr. Tobias, director of the Peter Jay Sharp Reconstructive and Aesthetic Breast Surgery program at Beth Israel, the primary referral for Fenway Community Health’s transgender health program, said it is fulfilling to work with the transgender and gender-nonconforming community.

“You can just tell, even in terms of how they act in the office consultation, they’re reticent and withdrawn,” he said. “But you walk into an exam room, with their gowns off and their shirts off, and you just think, ‘Who is this person?’ There’s a total change in an individual. It’s rewarding, which keeps us going.”

Dr. Tobias’ program launched nearly two years ago. He said the number of requests have been rising exponentially as more people feel comfortable coming out and taking medical strides to match their gender identities. He said he personally has done more than 100 surgeries for both transgender men and women.

In Worcester, UMass Memorial Medical Center – University Campus has also responded to the rise in demand. Last fall, the facility launched its first Youth Gender Services clinic for transgender and gender-nonconforming youth. Not all services lead to physical changes, and most begin with therapy and counseling.

Dr. Diane “Dede” Blake, who leads the UMass clinic with Dr. Penny M. Feldman, a pediatric endocrinologist, said their program is still in its infancy at North Lake Avenue in Worcester. The program has about 10 to 15 patients, many from Worcester County. The youngest patient is 11, and the pediatrician program accepts new clients up to age 19.

“That’s why I went into adolescent health in the first place,” Dr. Blake said. “To help people evolve into who they are to reach their potential.”

On the other side of the city, at 4 Mann St., is Safe Homes with the Bridge of Central Massachusetts, which offers a drop-in space for transgender and gender-nonconforming youth every Thursday night. Laura Farnsworth, Safe Homes’ program director, said she is happy to see UMass Memorial bringing this kind of clinic to Worcester. She said she refers her clients there, especially since it can be difficult for families to commute to Providence or Boston for services.

Striking statistics

Mr. Silverberg spends his spare time connecting with youth from across the country via social media who are questioning or struggling with their own identities, he said.

Though statistics for the demographic are difficult to track because so many people feel unsafe coming forward, experts estimate the national transgender population in the U.S. ranges from 1 percent to 3 percent – between roughly 3.2 million and 9.6 million across the country.

Dr. Ruben Hopwood, coordinator for Fenway Health’s transgender health program, said of that percentage, an estimated 41 percent has attempted suicide. That’s compared to the national attempted suicide rate at 1.6 percent and the rate for Massachusetts residents at just .6 percent.

“You’re not going to see any population that’s got a rate as high as 41 percent,” Dr. Hopwood said. “In some research, that number goes as high as 60 percent. ... There are increased rates of depression, anxiety, substance abuse and ineffective coping mechanisms for all kinds of distress you’ve got. That means shorter life spans. ... We see it compounded in this group in ways that show up astronomically high.”

Mr. Silverberg counts himself lucky as someone who didn't experience much strife in his coming out and then his pursuit of his physical transition. Today he said he is in awe of family and friends who have supported him fully.

Experts say the rate of violence, abuse and threats for transgender and gender-nonconforming are substantially higher than other populations as well, especially for transgender people of color.

Deborah Drew, Worcester Pride’s vice president and transgender activist, said she believes the transgender civil rights movement has hit a poignant moment in history at this time, with awareness rapidly growing. Still, Ms. Drew, an openly transgender woman, said the community is behind. She believes the LGBTQ community overall has made great strides, but the transgender population is still 20 years behind in its progress.

Attorney General Maura Healey, who has been outspoken in her support of the LGBTQ community, credited the recent rise of acceptance to publicity around two of the most public transgender women, Caitlyn Jenner, the former Olympic athlete Bruce Jenner, and transgender actress Laverne Cox, who plays a lead character in the Netflix series “Orange is the New Black.”

“A lot has happened when it comes to equality for gays and lesbians, and the transgender community has absolutely been told to ‘wait their turn’ by the public, lawmakers and others, so it’s understandable why they feel the time is now,” Ms. Healey said. “The good news is there is action and forward progress on this. We just need to keep going.”

Affording the care

Amid debates over bathroom legislation around the country, developments for the transgender community hit a high point in June when Defense Secretary Ashton B. Carter announced he would lift the Pentagon’s ban on transgender people serving openly in the armed forces. The New York Times reported Mr. Carter referred to the existing ban as “outdated.”

Mr. Silverberg served with the U.S. Army, studying explosive ordnance disposal in Alabama, but had to leave his training when he broke his foot at age 21. Though Mr. Silverberg wasn’t out as a “trans man” then, he would feel the effects of discrimination within the system years down the line.

As he sought to undergo a medical transition these last few months, he struggled with limiting health care coverage for transgender men and women available through the U.S. Department of Veteran Affairs' health care system. Eventually, he said, he found a new job as a security guard for Iron Mountain in Northboro to get more accommodating insurance coverage.

An inhibitor to pursue treatment is the high cost of therapy and procedures.

VA spokeswoman Ndidi Mojay said the agency's health care plan covers appointments for transgender, intersex and gender-nonconforming people up to the veteran’s surgery, and then any follow-up visits after that. The VA, however, does not cover surgeries and procedures for the population, she said, something that will likely “change in the future."

Chloe Gotsis, deputy press secretary for Ms. Healey, said the office reached out to the department recently to indicate the attorney general's support for lifting the restriction on gender-related surgeries covered by the VA’s health care. That proposal continues to work its way through the federal rule-making process.

An estimated 134,000 U.S. veterans are transgender, with more than 15,000 serving, according to the National Center for Transgender Equality.

Knowing at a young age

Mr. Silverberg laughed remembering how his mother said that when she was pregnant, she was told she was having a boy. It was a surprise when the opposite came out, Mr. Silverberg said with a laugh.

Talking recently about his adolescence, he said, “I dated boys and half-tried it, but I felt most like myself when I was like this,” motioning to his athletic garb. “When we were kids and playing house, I’d always be the dad and the husband, never the wife. My mom said she knew right away.”

Mr. Silverberg’s family is out of the norm in that nearly all of his relatives are extremely accepting. Statistics show that isn’t typically the case.

Mr. Silverberg has lived on and off with his grandparents, Susan and David Stirk, also of Shrewsbury, over the last few years. They said accepting their grandchild’s transition was easy from the start. The only challenge for them lies in getting the new pronouns right, along with the occasional term of endearment.

“Forever he was ‘Honey,’ and ‘Sweetheart,’ and all that,” Mr. Stirk, 72, said with a laugh.

Mr. Silverberg said for himself personally, he is more lax about the pronouns and hopes his family will adapt to them with time. He said he isn’t one to correct his loved ones.

“There was no question,” added Mrs. Stirk, 69. “Whatever he wanted was fine with us and we were very supportive and I have to say, because of that, the family looked at it that way. I said, ‘If I can accept it, you better well accept it.’ ”

Mr. Silverberg said his parents, who live in the area, are also supportive. His many aunts, uncles, cousins and sisters have visited him during his recovery to wish him well and to admire his new chest.

Mr. Stirk said he knows it would be harder for his grandchild to undergo his transition without their encouragement.

“That’s why we go out of our way to support him in all of his efforts, (so he can) become the person he wants to be,” he said.

Ms. Farnsworth said Safe Homes offers support to families as well. She noted many parents and guardians struggle with accepting a loved one’s new identity and stressed those feelings are still “valid.” Support groups with the tools and resources to help a family manage the transition can help everyone cope more easily, she said.

Beginning anew

Five days after his surgery, Mr. Silverberg sat proudly upright in his home in Grafton, sporting a tank top – the only article of clothing he refused to wear before the operation because he was too self-conscious, he said.

The shirt revealed a tattoo across both his arms that read, “Pain is inevitable. Suffering is optional.” He said he heard a pastor preach the quote once in a sermon when he was in the military, and it stuck with him.

Instead of feeling the discomfort of the surgery, Mr. Silverberg said he was only excited. He described it as feeling like a new person, so much so that he didn't need the pain medicine he was prescribed.

“I look at myself in the mirror like, ‘Hey,’ ” he said with a wink. “I feel 200 percent, even without the Oxys, because I feel like 200 percent.”

Mr. Silverberg, with inked arms featuring scenes from the Odyssey, said before the procedure, he hunched his back to hide his shape. Now, he said he can’t wait to get back outdoors or to go shirtless at the beach. Other plans include a large tattoo for across his chest, a step he always planned to take once the surgery was complete. He’s also researching 3-D tattoos for nipple designs; the feature was removed during the surgery process. That kind of tattooing is often sought by breast cancer survivors after mastectomies as well to repair their postsurgical chests.

The final frontier for Mr. Silverberg after that will be a legal name change.

Sitting on his couch with Ms. Depari and her 5-year-old daughter, Brooke, the family spoke of their future plans for traveling and moving. Mr. Silverberg today lives in an apartment on his uncle’s property. Ms. Depari, who grew up in Charlton and now lives in Lancaster, travels back and forth with Brooke to visit. She said she has always been accepting of her partner’s expression.

“I’m not the kind of person that cares about things like (physical appearance),” she said. “It’s the same for me. I think he will be more comfortable, but it’s the same for me.”

Mr. Silverberg and the little girl played together, whispering and tickling each other’s stomachs. Brooke calls Mr. Silverberg “Dad,” and the couple said they keep her in the loop on every new gender development, even at such a young age.

They said she understands what they mean. She even corrects her friends at school.

“Some of the kids tell her, ‘But that’s a girl,’ and she’s says, ‘Yeah, well, that’s still my dad!’ ” Mr. Silverberg said with his arm around the girl’s shoulders. “She’s quite informed.”

Mr. Silverberg, an avid skateboarder, now dreams of opening his own skate shop. He said he feels inspired to return to promoting the Sterling Royal fashion line, too, perhaps with a rebranding to match his own personal rebrand, he joked.

“Every day when I look in the mirror, just brushing my teeth or something, I’m just so pumped now,” he said. “I didn’t even know I had good shoulders. Now that I can actually see that every day, I’m just so excited.”