When he was 14 or 15, he read a piece by advice columnist Ann Landers that discussed the idea of being transgender. It was the first time he had heard the term.

“I went, ‘Oh, that’s it. That makes sense,’” he said.

In his mid-20s, he started going by Casey. He doesn’t want to share his given name, saying high school was a bad experience, which resulted in him dropping out.

It wasn’t until 1999, when he was in his mid-30s, that Sexton started taking testosterone. As he gradually took on more of a male appearance, people started treating him as a man.

But he still had large breasts, which he tried to conceal with a tight sports bra. “It was really uncomfortable because I looked like a guy, but people would touch my back, and I had a bra,” he said.

Working in restaurants and tiling floors, it wasn’t easy to save money for breast removal surgery. After his winnings at Dejope, now Ho-Chunk Gaming Madison, he went to Dr. Thomas Bartell, a plastic surgeon who did the operation in Madison.

Discovering a lump

In the spring of 2015, Sexton felt a lump, the size of an olive, below his right armpit.