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In the Operating Room During Gender Reassignment Surgery

Behind the scenes with identical twin Emmie Smith during her medical transition.

WATCH: FOLLOW A TRANSGENDER TEEN’S EMOTIONAL JOURNEY TO WOMANHOOD

Warning: graphic content.

Before August 30, 2016, getting stitches at age seven was the most time Emmie Smith had ever spent in a hospital.

That morning, she swapped her plaid shirt and jean shorts for a gown, tucked her hair into a cap, and prepared for surgery to conform her anatomy to the gender she already identified with: woman. In the operating room with her was National Geographic photographer Lynn Johnson. She and Emmie hoped they could demystify the procedure by documenting it, close-up and unflinching. “It was stressful and scary at times, but it almost created a mission other than just recovery,” Emmie says. “We were making something together.”

It had been a year and a half since Emmie had first come out as a transgender woman on Facebook. Telling her family and friends had been an enormous relief. “I’m not sure I could have taken another few years of being closeted,” she says.

Still, it was a challenging time for her family. Her mother, Reverend Kate Malin, is a prominent figure in their Massachusetts town, and her identical twin sons Caleb and Walker were familiar fixtures at her Episcopal church. A month after Walker came out as Emmie, Malin stepped out from behind her pulpit and walked into the aisle. Halfway through her sermon she decided it was time to address the change in her family.

“As most of you know, Bruce and I have three children,” she began. “Caleb and Walker, who are 17, and 13-year-old Owen. Walker’s new name is Emerson, and she prefers Emmie or Em. She’s wearing feminine clothing and makeup and will likely continue to move in the direction of a more feminized body.”

Kate nervously revealed her struggle to the attentive New England crowd. “I feel broken much of the time,” she confessed. “I’ve wanted to run away, and I’ve prayed for this child that I would gladly die for, guilty for how much I miss the person I thought was Walker and everything I thought might be.”

After the sermon, the congregation engulfed her in a hug. Then they moved to offer words of support to the sandy-haired 17-year-old sitting in the pews. In the first of many awkward mistakes the family would later laugh about, it was Caleb—Emmie’s identical twin.

After that sermon, a “new normal” set in. On a Saturday night soon after, they had their first “out” outing. Kate took Emmie—whose hair was still short and chest was flat—to buy a prom dress at David’s Bridal. She feared someone would point or laugh, but the crowds of brides and bridesmaids in the dressing room offered only compliments.

Though she hadn’t initially considered surgery, after a couple of months Emmie had grown frustrated by the tucking and taping required to fit into women’s clothes. That fall, her senior year of high school, she decided to do it.

But waking up after the operation, Emmie felt none of the immediate relief she’d expected. In the recovery room her earbuds played a soothing loop of Bon Iver and Simon and Garfunkel, but it didn’t drown out her disappointment and fear. In retrospect, she thought, hadn’t life before been OK?

It wasn’t until months later, when she was home and could walk and sit again, that Emmie knew she’d made the right choice. “If you’re not living freely that’s time wasted, and I felt my time was wasted pretending to be a boy,” she says. “It was the best decision in my life.”

Now, halfway through a gap year, she’s applying to college theater programs. It’s strange, she says, knowing that her future classmates may watch Johnson’s film and learn the most intimate details of her life. She’s hopeful that her participation will evolve the public’s understanding of gender reassignment surgery. “It’s not science fiction or mythology,” Emmie says. “It’s what happens to women just trying to be at peace with themselves and their bodies.”