As Marisa Ann Bella prepped for sex reassignment surgery 10 weeks ago, she gave her Mayo Clinic surgeons very explicit and morbid directions.

Mayo's first patient to ever undergo gender reassignment surgery told Jorys Martinez-Jorge and Oscar Manrique that they should finish the work, even if she flatlined on the operating table and was unable to be revived. After decades of waiting, the Rochester native was that determined to live or be buried as a woman.

Fortunately, the final step in Bella's transition went smoothly and she's now comfortable living in her own post-surgery body.

"It's indescribable," said Bella, who still lives in Rochester. "Before I would get sick to my stomach and literally throw up when I saw myself without clothes on and that was most of my adult and teen life. To see myself now, it's like night and day. This is the way it's supposed to be."

Despite that new outlook on life, it's been a bumpy ride to put it lightly. And many hurdles remain.

After 18 years of marriage, Marisa who then went by Michael came out to her family in 2010. It prompted an immediate divorce. When extended family also found out, they responded in a similar fashion.

That fallout prompted Marisa to consider suicide, going so far as taking a loaded gun to the banks of the Mississippi River. She says thinking of her twin daughters Gabriella and Isabella prevented her from pulling the trigger. Many in the transgender community struggle with suicide, with some studies suggesting 41 percent have attempted it.

But even their love was complicated.

Marisa was immediately supported by Gabriella and they moved to Andover after the divorce. Isabella had reservations about Marisa's decision, basically cutting off communication for two years while opting to live with her biological mother in Florida. Isabella's boyfriend and most of her classmates were unaware of those family issues until just this year.

"It changed our dynamic," Gabriella said. "I was more like if that's what you want to do, that's what you do. As a teenager, you yourself are trying to find your own identity. I think having Marisa kind of go through that same puberty-like change with us almost helped."

"My mother decided to show lots of hostility and regret and the family was very hostile. Marisa's family was not really accepting right away, and it separated the family because we were on different pages."

Time has healed some wounds, but not others. While Isabella has learned to become more comfortable and supportive around Marisa, the ex-wife has not. The twins have rented their own apartment in Florida since turning 18 in December, striking out on their own under the unusual circumstances.

While Marisa and Isabella are now on speaking terms, the daughter avoids using mom or dad. Instead, it's just Marisa.

"Even to this day, she's still more accepting than I am," Isabella said of her sister. "She's more (open) to the modern ideas, and I tend to be more traditional. I was a lot more religious than she was growing up, but she'll sit there and talk to Marisa about certain things that I don't.

"She understands for me it's a lot harder to accept, but if it makes (Marisa) happy, I'm going to support it."

Kicked out of U, accepted at Mayo

Marisa's initial transition care was handled by the University of Minnesota. It didn't quite go as planned.

She enrolled in hormone therapy while pursuing other medical options at the U's Center for Sexual Health, but felt there were gaps in her care. Specifically, she was seeking counseling and other support for her ongoing issues with post-traumatic stress disorder, depression and other related mental health concerns.

When Marisa complained about her therapist, she was eventually dropped from the U's Transgender Health Services program; Marisa claims she was deemed "too high maintenance."

As fate would have it, this occurred at virtually the same time Mayo opened its new specialty clinic in Rochester. Marisa was quickly enrolled and continued her transition while working with a voice therapist, having facial and breast surgeries and otherwise preparing to become Mayo's first patient to undergo vaginoplasty surgery.

"She was always anticipating when we were going to be able to offer this," said Dr. Todd Nippoldt, director of Mayo's Transgender and Intersex Specialty Care Clinic. "I remember from the start her saying 'I'll be your first patient' because it was very important to confirm her identity and live authentically."

With virtually no fanfare, the surgery was finally conducted Feb. 24. While the general public wouldn't notice anything different about Marisa, Mayo endocrinologist Caroline Davidge-Pitts says the transformation is obvious.

"Her whole face has changed," Davidge-Pitts said. "She just looks so happy."

That's the goal for every patient Mayo sees, according to Sharonne Hayes, M.D., medical director of the Office of Diversity and Inclusion.

"The Transgender and Intersex Specialty Care Clinic is another example of what sets Mayo Clinic apart a multidisciplinary, collaborative approach to care that meets all of the needs of each individual patient," Hayes said. "The specialty care clinic's patients work with their doctors, nurses, and the entire health care team to develop the right care plan, so that they can be their true selves."

As if the struggles with gender identity and family complications were enough, there's another demon lurking in Marisa's past.

As a member of the Boy Scouts of America during the 1970s, Marisa was one of many youths in Southeast Minnesota who were sexually assaulted by troop leader Richard Hokanson. According to a lawsuit filed in 2013 by Marisa and others under the Child Victims Act, the new Minnesota law eliminating the civil statute of limitations for children who were sexually abused, she was abused between the ages of 11 and 17.

The lawsuit alleged that the abuse was reported at age 13, but was allowed to continue for four more years. Marisa, as Keller, was the only victim to speak publicly about the abuse.

The lawsuit made headlines across the region, in part, because of who it named: Hokanson, the troop leader; St. Pius X Catholic Church, which sponsored the troop; the Boy Scouts of America; and Gamehaven Council, a branch of the Scouts in southeastern Minnesota.

Marisa who filed the lawsuit under her birth name, Michael Keller eventually settled the lawsuit out of court in 2014. The terms of the settlement are confidential.

She formally requested to be excommunicated from the Catholic Church on Feb. 28, 2014, almost exactly two years before undergoing gender confirmation surgery at Mayo. She's currently on disability from that surgery, but hopes to return to her career in the airline industry within a year.

"This is not the church of Jesus Christ, but a group of perverted old men who hid like cowards behind secrecy and shame," Keller wrote through his attorney to Bishop John Quinn. "The Catholic Church never apologized or offered to help with the healing process."

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Difficult road for Mayo's first sex reassignment patient - Post-Bulletin

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