gender reassignment history

May 10, 2021

The Forgotten History of the World's First Trans Clinic

The Institute for Sexual Research in Berlin would be a century old if it hadn’t fallen victim to Nazi ideology

By Brandy Schillace

Costume party at the Institute for Sexual Research in Berlin, date and photographer unknown. Magnus Hirschfeld ( in glasses ) holds hands with his partner, Karl Giese ( center ).

Magnus-Hirschfeld-Gesellschaft e.V., Berlin

Late one night on the cusp of the 20th century, Magnus Hirschfeld, a young doctor, found a soldier on the doorstep of his practice in Germany. Distraught and agitated, the man had come to confess himself an Urning —a word used to refer to homosexual men. It explained the cover of darkness; to speak of such things was dangerous business. The infamous “Paragraph 175” in the German criminal code made homosexuality illegal; a man so accused could be stripped of his ranks and titles and thrown in jail.

Hirschfeld understood the soldier’s plight—he was himself both homosexual and Jewish—and did his best to comfort his patient. But the soldier had already made up his mind. It was the eve of his wedding, an event he could not face . Shortly after, he shot himself.

The soldier bequeathed his private papers to Hirschfeld, along with a letter: “The thought that you could contribute to [a future] when the German fatherland will think of us in more just terms,” he wrote, “sweetens the hour of death.” Hirschfeld would be forever haunted by this needless loss; the soldier had called himself a “curse,” fit only to die, because the expectations of heterosexual norms, reinforced by marriage and law, made no room for his kind. These heartbreaking stories, Hirschfeld wrote in The Sexual History of the World War , “bring before us the whole tragedy [in Germany]; what fatherland did they have, and for what freedom were they fighting?” In the aftermath of this lonely death, Hirschfeld left his medical practice and began a crusade for justice that would alter the course of queer history.

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Hirschfeld sought to specialize in sexual health, an area of growing interest. Many of his predecessors and colleagues believed that homosexuality was pathological, using new theories from psychology to suggest it was a sign of mental ill health. Hirschfeld, in contrast, argued that a person may be born with characteristics that did not fit into heterosexual or binary categories and supported the idea that a “third sex” (or Geschlecht ) existed naturally. Hirschfeld proposed the term “sexual intermediaries” for nonconforming individuals. Included under this umbrella were what he considered “situational” and “constitutional” homosexuals—a recognition that there is often a spectrum of bisexual practice—as well as what he termed “transvestites.” This group included those who wished to wear the clothes of the opposite sex and those who “from the point of view of their character” should be considered as the opposite sex. One soldier with whom Hirschfeld had worked described wearing women’s clothing as the chance “to be a human being at least for a moment.” He likewise recognized that these people could be either homosexual or heterosexual, something that is frequently misunderstood about transgender people today.

Magnus Hirschfeld, director of the Institute for Sexual Research, in an undated portrait. Credit: Magnus-Hirschfeld-Gesellschaft e.V., Berlin

Perhaps even more surprising was Hirschfeld’s inclusion of those with no fixed gender, akin to today’s concept of gender-fluid or nonbinary identity (he counted French novelist George Sand among them). Most important for Hirschfeld, these people were acting “in accordance with their nature,” not against it.

If this seems like extremely forward thinking for the time, it was. It was possibly even more forward than our own thinking, 100 years later. Current anti-trans sentiments center on the idea that being transgender is both new and unnatural. In the wake of a U.K. court decision in 2020 limiting trans rights, an editorial in the Economist argued that other countries should follow suit , and an editorial in the Observer praised the court for resisting a “disturbing trend” of children receiving gender-affirming health care as part of a transition.

Related: The Disturbing History of Research into Transgender Identity

But history bears witness to the plurality of gender and sexuality. Hirschfeld considered Socrates, Michelangelo and Shakespeare to be sexual intermediaries; he considered himself and his partner Karl Giese to be the same. Hirschfeld’s own predecessor in sexology, Richard von Krafft-Ebing, had claimed in the 19th century that homosexuality was natural sexual variation and congenital.

Hirschfeld’s study of sexual intermediaries was no trend or fad; instead it was a recognition that people may be born with a nature contrary to their assigned gender. And in cases where the desire to live as the opposite sex was strong, he thought science ought to provide a means of transition. He purchased a Berlin villa in early 1919 and opened the Institut für Sexualwissenschaft (the Institute for Sexual Research) on July 6. By 1930 it would perform the first modern gender-affirmation surgeries in the world.

A Place of Safety

A corner building with wings to either side, the institute was an architectural gem that blurred the line between professional and intimate living spaces. A journalist reported it could not be a scientific institute, because it was furnished, plush and “full of life everywhere.” Its stated purpose was to be a place of “research, teaching, healing, and refuge” that could “free the individual from physical ailments, psychological afflictions, and social deprivation.” Hirschfeld’s institute would also be a place of education. While in medical school, he had experienced the trauma of watching as a gay man was paraded naked before the class, to be verbally abused as a degenerate.

Hirschfeld would instead provide sex education and health clinics, advice on contraception, and research on gender and sexuality, both anthropological and psychological. He worked tirelessly to try to overturn Paragraph 175. Unable to do so, he got legally accepted “transvestite” identity cards for his patients, intended to prevent them from being arrested for openly dressing and living as the opposite sex. The grounds also included room for offices given over to feminist activists, as well as a printing house for sex reform journals meant to dispel myths about sexuality. “Love,” Hirschfeld said, “is as varied as people are.”

The institute would ultimately house an immense library on sexuality, gathered over many years and including rare books and diagrams and protocols for male-to-female (MTF) surgical transition. In addition to psychiatrists for therapy, he had hired Ludwig Levy-Lenz, a gynecologist. Together, with surgeon Erwin Gohrbandt, they performed male-to-female surgery called Genitalumwandlung —literally, “transformation of genitals.” This occurred in stages: castration, penectomy and vaginoplasty. (The institute treated only trans women at this time; female-to-male phalloplasty would not be practiced until the late 1940s.) Patients would also be prescribed hormone therapy, allowing them to grow natural breasts and softer features.

Their groundbreaking studies, meticulously documented, drew international attention. Legal rights and recognition did not immediately follow, however. After surgery, some trans women had difficulty getting work to support themselves, and as a result, five were employed at the institute itself. In this way, Hirschfeld sought to provide a safe space for those whose altered bodies differed from the gender they were assigned at birth—including, at times, protection from the law.

1926 portrait of Lili Elbe, one of Hirschfeld's patients. Elbe's story inspired the 2015 film The Danish Girl . Credit: https://wellcomeimages.org/indexplus/image/L0031864.html (CC BY 4.0)

Lives Worth Living

That such an institute existed as early as 1919, recognizing the plurality of gender identity and offering support, comes as a surprise to many. It should have been the bedrock on which to build a bolder future. But as the institute celebrated its first decade, the Nazi party was already on the rise. By 1932 it was the largest political party in Germany, growing its numbers through a nationalism that targeted the immigrant, the disabled and the “genetically unfit.” Weakened by economic crisis and without a majority, the Weimar Republic collapsed.

Adolf Hitler was named chancellor on January 30, 1933, and enacted policies to rid Germany of Lebensunwertes Leben , or “lives unworthy of living.” What began as a sterilization program ultimately led to the extermination of millions of Jews, Roma, Soviet and Polish citizens—and homosexuals and transgender people.

When the Nazis came for the institute on May 6, 1933, Hirschfeld was out of the country. Giese fled with what little he could. Troops swarmed the building, carrying off a bronze bust of Hirschfeld and all his precious books, which they piled in the street. Soon a towerlike bonfire engulfed more than 20,000 books, some of them rare copies that had helped provide a historiography for nonconforming people.

The carnage flickered over German newsreels. It was among the first and largest of the Nazi book burnings. Nazi youth, students and soldiers participated in the destruction, while voiceovers of the footage declared that the German state had committed “the intellectual garbage of the past” to the flames. The collection was irreplaceable.

Levy-Lenz, who like Hirschfeld was Jewish, fled Germany. But in a dark twist, his collaborator Gohrbandt, with whom he had performed supportive operations, joined the Luftwaffe as chief medical adviser and later contributed to grim experiments in the Dachau concentration camp. Hirschfeld’s likeness would be reproduced on Nazi propaganda as the worst kind of offender (both Jewish and homosexual) to the perfect heteronormative Aryan race.

In the immediate aftermath of the Nazi raid, Giese joined Hirschfeld and his protégé Li Shiu Tong, a medical student, in Paris. The three would continue living together as partners and colleagues with hopes of rebuilding the institute, until the growing threat of Nazi occupation in Paris required them to flee to Nice. Hirschfeld died of a sudden stroke in 1935 while still on the run. Giese died by suicide in 1938. Tong abandoned his hopes of opening an institute in Hong Kong for a life of obscurity abroad.

Over time their stories have resurfaced in popular culture. In 2015, for instance, the institute was a major plot point in the second season of the television show Transparent , and one of Hirschfeld’s patients, Lili Elbe, was the protagonist of the film The Danish Girl . Notably, the doctor’s name never appears in the novel that inspired the movie, and despite these few exceptions the history of Hirschfeld’s clinic has been effectively erased. So effectively, in fact, that although the Nazi newsreels still exist, and the pictures of the burning library are often reproduced, few know they feature the world’s first trans clinic. Even that iconic image has been decontextualized, a nameless tragedy.

The Nazi ideal had been based on white, cishet (that is, cisgender and heterosexual) masculinity masquerading as genetic superiority. Any who strayed were considered as depraved, immoral, and worthy of total eradication. What began as a project of “protecting” German youth and raising healthy families had become, under Hitler, a mechanism for genocide.

One of the first and largest Nazi book burnings destroyed the library at the Institute for Sexual Research. Credit: Ullstein Bild and Getty Images

A Note for the Future

The future doesn’t always guarantee progress, even as time moves forward, and the story of the Institute for Sexual Research sounds a warning for our present moment. Current legislation and indeed calls even to separate trans children from supportive parents bear a striking resemblance to those terrible campaigns against so-labeled aberrant lives.

Studies have shown that supportive hormone therapy, accessed at an early age, lowers rates of suicide among trans youth. But there are those who reject the evidence that trans identity is something you can be “born with.” Evolutionary biologist Richard Dawkins was recently stripped of his “humanist of the year” award for comments comparing trans people to Rachel Dolezal , a civil rights activist who posed as a Black woman, as though gender transition were a kind of duplicity. His comments come on the heels of legislation in Florida aiming to ban trans athletes from participating in sports and an Arkansas bill denying trans children and teens supportive care.

Looking back on the story of Hirschfeld’s institute—his protocols not only for surgery but for a trans-supportive community of care, for mental and physical healing, and for social change—it’s hard not to imagine a history that might have been. What future might have been built from a platform where “sexual intermediaries” were indeed thought of in “more just terms”? Still, these pioneers and their heroic sacrifices help to deepen a sense of pride—and of legacy—for LGBTQ+ communities worldwide. As we confront oppressive legislation today, may we find hope in the history of the institute and a cautionary tale in the Nazis who were bent on erasing it.

Brandy Schillace is editor in chief of BMJ's Medical Humanities journal and author of the recently released book Mr. Humble and Doctor Butcher , a biography of Robert White, who aimed to transplant the human soul.

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• The rise and fall of gende...

The rise and fall of gender identity clinics in the 1960s and 1970s

Editor’s note: this article is based on the second-place poster in the american college of surgeons history of surgery poster contest at the virtual clinical congress 2020. the authors note that as the field of medicine and society have evolved to better understand the experiences of transgender individuals, terminology has changed significantly. the authors have […].

Melanie Fritz, Nat Mulkey

April 1, 2021

Editor’s note: This article is based on the second-place poster in the American College of Surgeons History of Surgery poster contest at the virtual Clinical Congress 2020. The authors note that as the field of medicine and society have evolved to better understand the experiences of transgender individuals, terminology has changed significantly. The authors have kept the original wording of direct quotes, but elsewhere in the article terminology is used that is consistent with present-day standards; that is, “transgender” or “transgender and gender nonbinary.”

HIGHLIGHTS Summarizes early pioneering work in the GAS field in the U.S. and Europe Describes the effects of clinic closures in the 1970s Outlines the resurgence of multidisciplinary clinics for TGNB patients at academic centers and in private practice Identifies ongoing barriers related to GAS, including financial concerns and access to reliable information

Transgender and gender nonbinary (TGNB) individuals have existed for thousands of years and in cultures throughout the world. In Western medicine, however, the modern era of gender-affirming surgery (GAS) began at the Institute of Sexual Research in Berlin, Germany, under the leadership of Magnus Hirschfeld, MD. Surgeons at the institute performed the earliest vaginal constructions in the 1930s. Early patients included an employee of the facility, known by the last name of Dorchen, and the Danish painter Lili Elbe, whose story was depicted in the 2015 film The Danish Girl . 1

Around the same time that Dr. Hirschfeld’s institute began performing vaginoplasties, the father of plastic surgery, Sir Harold Gillies, OBE, FRCS, had been refining techniques for genital construction in Britain. He did so primarily by operating on British men who had sustained genital injuries during wartime and subsequently presented to him for assistance. In the 1940s, he performed the first known phalloplasty for a transgender patient on Michael Dillon, MD, a British physician. Dr. Gillies later performed a vaginoplasty on patient Roberta Cowell, who gained some renown in Britain. 2

In the 1950s, Georges Burou, MD, began performing vaginoplasty operations in Casablanca, Morocco, and is widely credited with inventing the anteriorly pedicled penile skin flap inversion vaginoplasty. 3

Increased awareness in the U.S.

One of the earliest known GAS procedures performed in the U.S. was for patient Alan Hart, MD, a transgender man and physician, who underwent a hysterectomy in 1910. 1

The field of GAS subsequently remained dormant in the U.S. until the 1950s, when pioneers like Elmer Belt, MD, University of California Los Angeles, and Milton Edgerton, MD, Johns Hopkins University (JHU) began performing GAS. 4,5

The work of sexologist and endocrinologist Harry Benjamin, MD, in the 1950s and 1960s provided additional momentum to the field within the medical community. At the time, many psychiatrists and physicians believed that the correct approach to treating transgender patients was exclusively through psychoanalytic therapy aimed at altering the desire to live as a different gender. Dr. Benjamin is attributed with being one of the first physicians to challenge this notion.

In 1966, he published The Transsexual Phenomenon , which detailed the era’s approach to GAS. 4 Notably, this text includes far more detail about male-to-female (MTF) surgical operations, such as vaginoplasty, than female-to-male (FTM) operations, such as phalloplasty or metoidioplasty. At the time, transgender men were incorrectly believed to be less common than transgender women, and surgeons were reluctant to perform FTM GAS procedures. Based on writings from the era, some of this reluctance stemmed from uncertainty as to whether surgical techniques were capable of constructing a neophallus that would be satisfactory to the patient. 6

A boom of awareness of GAS within both the field of medicine and the larger U.S. public can primarily be attributed to one individual: Christine Jorgensen. Ms. Jorgensen was a transgender woman who captured the attention and interest of the general public after undergoing a series of operations for GAS in Denmark from 1951 to 1952. 4 Her coming out story and transition were covered extensively in popular media, appearing in the New York Daily News under the eye-catching headline “Ex-GI Becomes Blonde Beauty.” 7

Wave of clinics providing GAS

Publication of Dr. Benjamin’s book coincided with the public announcement of JHU Gender Identity Clinic in November 1966. 8 While several major academic centers had internally discussed the formation of research institutes to study the treatment of transgender patients since the early 1960s, the opening of the JHU clinic marked a transition from quiet deliberation to public recruitment for research on GAS. Initiatives quickly sprung up at many major universities and hospitals, marked by interdisciplinary collaboration between psychiatrists, urologists, plastic surgeons, gynecologists, and social workers. While estimates vary, the increase in U.S. patients who underwent GAS was dramatic, growing to more than 1,000 by the end of the 1970s from approximately 100 patients in 1969. 5,9

Producing positive results in a stigmatized field

Whereas GAS was a new endeavor for U.S. physicians, these clinics primarily operated as research programs. As a new field of practice, the physicians involved in the clinics faced significant skepticism from colleagues, such as psychiatrist Joost Meerloo, MD, who outlined his concerns in the American Journal of Psychiatry in 1967. Dr. Meerloo wrote, “Unwittingly, many a physician does not treat the disease as such but treats, rather, the fantasy a patient develops about his disease…I believe the surgical treatment of transsexual yearnings easily falls into this trap…. What about our medical responsibility and ethics? Do we have to collaborate with the sexual delusions of our patients?” 10

Understandably, physicians involved in these gender identity clinics described feeling pressure to demonstrate successful postoperative outcomes in order to justify their work. In the introduction to a published case series on GAS, Norman Fisk, MD, a psychiatrist at Stanford University, CA, wrote, “In our efforts we were preoccupied with obtaining good results. This preoccupation, we believed, would enable us to continue our work in an area where many professional colleagues had, and retain, serious doubts as to the validity of gender reorientation.” 11

In an attempt to obtain good results, these clinics often maintained rigorous selection criteria that excluded a number of patients. The evaluation process required that patients undergo hormone treatment and live for a set period of time as the gender to which they intended to transition. This period of time could extend up to five years depending on the clinic, imposing a significant burden on patients. As one patient, transgender man Mario Martino, stated, “One talks of a period of two to five years. I agree that people should be tested. I think that they should be tested in every way possible before being accepted as a candidate for treatment. However, one of the problems that people tend to forget is that a female with a 48-inch bust cannot pass as a male for one day, much less for one year or five years, no matter how much he tries.” 12

Individuals who were considered traditionally attractive and were expected to be easily perceived as a member of the other sex, as well as individuals who were heterosexual per their gender identity, were considered better surgical candidates. To demonstrate the scale of this selectivity, out of 2,000 applications sent to JHU within two years of opening, only 24 patients underwent an operation. 5,11,13

Though early studies were small, many did, in fact, demonstrate successful psychiatric outcomes. A report from Edgerton and colleagues in 1970 found that at one to two years postoperatively, of nine patients who underwent GAS, all were glad to have undergone surgery, had greater self-confidence, and held “a brighter outlook for their future.” 5 When considering the competing demands of producing positive outcomes and providing GAS to patients in need, it’s clear how physicians working in these clinics were confronted with challenges in their roles. They were advocates for a marginalized population, and yet they also functioned as gatekeepers for thousands of transgender patients desperate for surgery and who faced reinforced gender-based stereotypes as described earlier in the eligibility criteria.

Timeline and clinic closure

Toward the end of the 1970s, many centers closed their doors to new patients. These closures often were kept out of the public eye, making it difficult to discern precise timing or causes. There were, however, two notable exceptions to the pattern of patient enrollment quietly declining and ceasing.

At JHU, a new chair of psychiatry, Paul McHugh, MD, was hired in 1975. Dr. McHugh disapproved of offering GAS to transgender patients and acknowledged that from the moment he was hired, he intended to stop this practice at the clinic. Under his leadership, JHU psychiatrist Jon Meyer, MD, published a study of 50 surgical patients from the JHU clinic, which concluded that GAS offered “no objective benefit” for transgender people. Although this claim directly contradicted a growing body of evidence that found significant benefit for transgender patients, the publication sparked the rapid closure of the JHU clinic in 1979. 14

FIGURE 1. GENDER IDENTITY CLINIC TIMELINE

Another gender identity clinic where operations were abruptly terminated was the Baptist Medical Center in Oklahoma City. The Gender Identity Foundation at the center had offered a variety of services for transgender patients, including GAS, since 1973, under the radar of local religious leaders. In 1977, however, the issue of GAS was brought to the attention of the board of directors of the Baptist General Convention of Oklahoma. The physicians involved fervently advocated to be allowed to continue their practice, including surgeons Charles L. Reynolds, Jr., MD, FACS, and David W. Foerster, MD, FACS, who issued a joint statement that said, “[I]f Jesus Christ were alive today, undoubtedly he would render help and comfort to the transsexual.” Despite these appeals, the board of directors voted 54–2 to ban GAS at the Baptist Medical Center. 15

Given the known timing of when these two clinics closed, they are marked with a box in a timeline constructed by the authors (see Figure 1). The remaining end dates are estimates derived from the latest reported operations in the medical literature and news articles, which likely underestimate the length of time the clinics were in operation. The reasons for closure of the remaining clinics appear to be multifactorial.

The publicity around the Meyer paper that led to JHU’s clinic closure may have played a role in the decision to close other clinics. 16 In addition, some clinics described financial challenges during this time, as patients often were unable to afford the expensive operations, and insurance companies refused to cover them. For example, at the University of Minnesota, Minneapolis, clinic, the first two dozen operations were funded by a research grant at the expense of the state, but a news article from 1972 suggests that funding difficulties were exacerbated when the state no longer wanted to fund the project. 9 Institutional pushback, such as that experienced at JHU, and the retirement of leading surgeons also may have played a role in the closure of gender identity clinics across the nation.

Even though many clinics’ GAS-related research was winding down in the late 1970s, the last 15 years of academic interest motivated the 1979 establishment of the Harry Benjamin International Gender Dysphoria Association. This organization, formed with the goal of organizing professionals who were “interested in the study and care of transexualism and gender dysphoria,” has since been renamed the World Professional Association for Transgender Health (WPATH) and has grown into an international interdisciplinary organization. 17 WPATH has established internationally accepted guidelines for treating individuals with gender dysphoria, which are periodically updated. The most recent of these guidelines is the Standards of Care Version 7 (SOC7). 18 Today, insurance companies, national payors, and treatment teams in both the U.S. and Europe use the WPATH SOC7 guidelines for establishing surgical eligibility.

Present day significance

The contemporaneous evolution of the first wave of gender identity clinics generated a rich field for refinement of surgical technique, as well as the assessment of postoperative outcomes, and produced a foundation of scientific literature demonstrating successful psychiatric outcomes for transgender people undergoing GAS. These milestones foreshadowed a resurgence of multidisciplinary clinics for TGNB individuals in academic centers and paved the way for private practitioners to specialize in GAS. For example, Stanley Biber, MD, a private practice surgeon in Colorado, performed more than 5,000 GAS operations during his 35 years in practice. 19

Many centers for transgender medicine and surgery now exist across the U.S., and the number of GAS operations being performed in the U.S. has increased substantially, along with expanded insurance coverage. In 2015, the U.S. Transgender Survey found that 25 percent of TGNB individuals had one or more gender-affirming operations. 20 Similar to the earlier wave of clinics, present-day clinics still are frequently composed of an interdisciplinary team of primary care, surgical, and mental health professionals.

Although the number of GAS continues to increase, the current discourse echoes earlier concerns about how to limit barriers for this marginalized population while prioritizing positive surgical outcomes. The WPATH standards of care often function as guides to assist health care centers in creating TGNB health programs. 21 The WPATH SOCs have evolved since their establishment and presently tend to include fewer preoperative requirements for TGNB patients than in the 1970s and 1980s.

However, TGNB patients continue to face significant barriers to accessing GAS. A 2018 survey of TGNB patients found that the most commonly cited barriers to gender-affirming care are financial concerns, access to physicians who are knowledgeable about GAS, and access to reliable information. 22 These financial concerns can be exacerbated by the cost of obtaining the mental health evaluations recommended by WPATH SOC7, and challenges associated with insurance coverage. 23 To address these barriers, institutions are considering preoperative models besides the WPATH SOC7 to potentially reduce challenges.

Moreover, general medical education initiatives are under way to increase provider knowledge about this population. 24,25 As the field of GAS continues to evolve in the present day, we look forward to seeing how the surgical and medical community partners with patients to minimize these barriers and promote access to these essential surgical treatments.

• Denny D. Gender reassignment surgeries in the XXth century. Workshop at 9th Transgender Lives: The Intersection of Health and Law Conference, Farmington, CT. May 10, 2015. Available at: http://dallasdenny.com/Writing/2015/05/10/gender-reassignment-surgeries-in-the-xxth-century-2015/ . Accessed February 11, 2021.
• Kennedy P. The First Man-Made Man: The Story of Two Sex Changes, One Love Affair, and a Twentieth-Century Medical Revolution . New York: Bloomsbury USA; 2007.
• Hage JJ, Kareem RB, Laub DR. On the origin of pedicled skin inversion vaginoplasty: Life and work of Dr. Georges Burou of Casablanca. Ann Plast Surg . 2007;59(6):723-729.
• Benjamin H. The Transsexual Phenomenon . New York, New York: Warner Books Incorporated; 1966.
• Edgerton MT, Knorr NJ, Callison JR. The surgical treatment of transsexual patients. Limitations and indications. Plast Reconstr Surg . 1970;45(1):38-46.
• Williams G. An approach to transsexual surgery. Nurs Times . 1973;69(25):787.
• Ex-GI becomes blonde beauty: Operations transform Bronx youth. New York Daily News . December 1, 1952:75. Available at: www.newspapers.com/clip/25375703/ex-gi-becomes-blonde-beauty/ . Accessed March 22, 2021.
• Buckley T. A changing of sex by surgery begun at Johns Hopkins. The New York Times . November 21, 1966. Available at: www.nytimes.com/1966/11/21/archives/a-changing-of-sex-by-surgery-begun-at-johns-hopkins-johns-hopkins.html . Accessed March 22, 2021.
• Brody J. 500 in the U.S. change sex in six years with surgery. The New York Times . Nov 20, 1972. Available at: www.nytimes.com/1972/11/20/archives/500-in-the-u-s-change-sex-in-six-years-with-surgery-500-change-sex.html . Accessed February 11, 2021.
• Meerloo JA. Change of sex and collaboration with the psychosis. Am J Psychiatry . 1967;124(2):263-264.
• Fisk NM. Five spectacular results. Arch Sex Behav . 1978;7(4):351-369.
• Money J. Transsexualism: Open forum. Arch Sex Behav . 1978;7(4):387-415.
• Hastings D, Markland C. Post-surgical adjustment of 25 transsexuals at University of Minnesota. Arch Sex Behav . 1978;7(4):327-336.
• Siotos C, Neira PM, Lau BD, et al. Origins of gender affirmation surgery: The history of the first gender identity clinic in the United States at Johns Hopkins. Ann Plast Surg . 2019;83(2):132-136.
• Baptists vote to ban sex change operations. Sarasota Herald-Tribune . October 15, 1977.
• Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins. Washington Post . April 5, 2017. Available at: www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.html . Accessed February 11, 2021.
• Walker PA. The University of Texas Medical Branch. Memo to persons interested in the Harry Benjamin International Gender Dysphoria Association. April 17, 1979. Available at: www.wpath.org/media/cms/Documents/History/Harry%20Benjamin/First%20HBIGDA%20Membership%20Request%20Letter%201979.pdf . Accessed February 11, 2021.
• Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend . 2012;13(4):165-232.
• Arrillaga P. Onetime coal mining town bolstered by changing economy. Los Angeles Times . June 4, 2000. Available at: www.latimes.com/archives/la-xpm-2000-jun-04-me-37512-story.html . Accessed February 11, 2021.
• James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 Transgender Survey. Washington, DC: National Center for Healthcare Equality, 2016. Available at: www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF . Accessed February 11, 2021.
• National LGBT Health Education Center. Creating a transgender health program at your health center: Planning to implementation. September 2018. Available at: www.lgbtqiahealtheducation.org/wp-content/uploads/2018/10/Creating-a-Transgender-Health-Program.pdf . Accessed February 11, 2021.
• El-Hadi H, Stone J, Temple-Oberle C, Harrop AR. Gender-affirming surgery for transgender individuals: Perceived satisfaction and barriers to care. Plast Surg . 2018;26(4):263-268.
• Puckett JA, Cleary P, Rossman K, Newcomb ME, Mustanski B. Barriers to gender-affirming care for transgender and gender nonconforming individuals. Sex Res Social Policy . 2018;15(1):48-59.
• Lichtenstein M, Stein L, Connolly E, et al. The Mount Sinai patient-centered preoperative criteria meant to optimize outcomes are less of a barrier to care than WPATH SOC 7 criteria before transgender-specific surgery. Transgend Health . 2020;5(3):166-172.
• Streed CG, Davis JA. Improving clinical education and training on sexual and gender minority health. Curr Sex Health Rep . 2018;10:273-280.

Origins of Gender Affirmation Surgery: The History of the First Gender Identity Clinic in the United States at Johns Hopkins

• Johns Hopkins Health System
• School of Medicine

Research output : Contribution to journal › Article › peer-review

Background Gender-affirming care, including surgery, has gained more attention recently as third-party payers increasingly recognize that care to address gender dysphoria is medically necessary. As more patients are covered by insurance, they become able to access care, and transgender cultural competence is becoming recognized as a consideration for health care providers. A growing number of academic medical institutions are beginning to offer focused gender-affirming medical and surgical care. In 2017, Johns Hopkins Medicine launched its new Center for Transgender Health. In this context, history and its lessons are important to consider. We sought to evaluate the operation of the first multidisciplinary Gender Identity Clinic in the United States at the Johns Hopkins Hospital, which helped pioneer what was then called "sex reassignment surgery." Methods We evaluated the records of the medical archives of the Johns Hopkins University. Results We report data on the beginning, aim, process, outcomes of the clinic, and the reasons behind its closure. This work reveals the function of, and the successes and challenges faced by, this pioneering clinic based on the official records of the hospital and mail correspondence among the founders of the clinic. Conclusion This is the first study that highlights the role of the Gender Identity Clinic in establishing gender affirmation surgery and reveals the reasons of its closure.

• gender dysphoria
• gender identity
• interdisciplinary studies
• sex reassignment surgery

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• History Medicine & Life Sciences 100%
• Sex Reassignment Surgery Medicine & Life Sciences 43%
• Gender Dysphoria Medicine & Life Sciences 42%
• Cultural Competency Medicine & Life Sciences 37%
• Health Insurance Reimbursement Medicine & Life Sciences 36%
• Hospital Records Medicine & Life Sciences 30%
• Postal Service Medicine & Life Sciences 29%
• Insurance Medicine & Life Sciences 27%

T1 - Origins of Gender Affirmation Surgery

T2 - The History of the First Gender Identity Clinic in the United States at Johns Hopkins

AU - Siotos, Charalampos

AU - Neira, Paula M.

AU - Lau, Brandyn D.

AU - Stone, Jill P.

AU - Page, James

AU - Rosson, Gedge D.

AU - Coon, Devin

N1 - Publisher Copyright: © Wolters Kluwer Health, Inc. All rights reserved.

PY - 2019/8/1

Y1 - 2019/8/1

N2 - Background Gender-affirming care, including surgery, has gained more attention recently as third-party payers increasingly recognize that care to address gender dysphoria is medically necessary. As more patients are covered by insurance, they become able to access care, and transgender cultural competence is becoming recognized as a consideration for health care providers. A growing number of academic medical institutions are beginning to offer focused gender-affirming medical and surgical care. In 2017, Johns Hopkins Medicine launched its new Center for Transgender Health. In this context, history and its lessons are important to consider. We sought to evaluate the operation of the first multidisciplinary Gender Identity Clinic in the United States at the Johns Hopkins Hospital, which helped pioneer what was then called "sex reassignment surgery." Methods We evaluated the records of the medical archives of the Johns Hopkins University. Results We report data on the beginning, aim, process, outcomes of the clinic, and the reasons behind its closure. This work reveals the function of, and the successes and challenges faced by, this pioneering clinic based on the official records of the hospital and mail correspondence among the founders of the clinic. Conclusion This is the first study that highlights the role of the Gender Identity Clinic in establishing gender affirmation surgery and reveals the reasons of its closure.

AB - Background Gender-affirming care, including surgery, has gained more attention recently as third-party payers increasingly recognize that care to address gender dysphoria is medically necessary. As more patients are covered by insurance, they become able to access care, and transgender cultural competence is becoming recognized as a consideration for health care providers. A growing number of academic medical institutions are beginning to offer focused gender-affirming medical and surgical care. In 2017, Johns Hopkins Medicine launched its new Center for Transgender Health. In this context, history and its lessons are important to consider. We sought to evaluate the operation of the first multidisciplinary Gender Identity Clinic in the United States at the Johns Hopkins Hospital, which helped pioneer what was then called "sex reassignment surgery." Methods We evaluated the records of the medical archives of the Johns Hopkins University. Results We report data on the beginning, aim, process, outcomes of the clinic, and the reasons behind its closure. This work reveals the function of, and the successes and challenges faced by, this pioneering clinic based on the official records of the hospital and mail correspondence among the founders of the clinic. Conclusion This is the first study that highlights the role of the Gender Identity Clinic in establishing gender affirmation surgery and reveals the reasons of its closure.

KW - gender dysphoria

KW - gender identity

KW - interdisciplinary studies

KW - sex reassignment surgery

UR - http://www.scopus.com/inward/record.url?scp=85069507993&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85069507993&partnerID=8YFLogxK

U2 - 10.1097/SAP.0000000000001684

DO - 10.1097/SAP.0000000000001684

M3 - Article

C2 - 30557186

AN - SCOPUS:85069507993

SN - 0148-7043

JO - Annals of plastic surgery

JF - Annals of plastic surgery

Brief History of Gender Affirmation Medicine and Surgery

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• Jasmine Bhinder 3 &
• Prashant Upadhyaya 3  

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Gender dysphoria is the inner conflict and distress caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth. The earliest reports of gender identity alteration can be traced back to 1500 BC in ancient Egypt and during the Roman Empire (509 to 27 BC). During the modern era, Magnus Hirschfeld was considered the father of transgender healthcare and established the Institute for Sexual Science in Berlin. This was the world’s first institute devoted to sexology and was the site of the first documented gender affirmation surgery: orchiectomy, penectomy, and vaginoplasty in a transgender female patient. Dr. Harry Benjamin was a close friend of Hirschfeld who also had a keen interest in transgender healthcare and advocacy. Dr. Benjamin assisted hundreds of transgender individuals by prescribing hormones and suggested they visit surgeons abroad for gender affirmation surgeries. He later founded the Harry Benjamin International Gender Dysphoria Association (HBIGDA), which outlined standards of care for transgender individuals who desired medical and surgical treatment. In 2007, HBIGDA became known as the World Professional Association for Transgender Health (WPATH), which is a professional organization dedicated to the care and treatment of individuals with gender dysphoria today.

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Bhinder, J., Upadhyaya, P. (2021). Brief History of Gender Affirmation Medicine and Surgery. In: Nikolavsky, D., Blakely, S.A. (eds) Urological Care for the Transgender Patient. Springer, Cham. https://doi.org/10.1007/978-3-030-18533-6_19

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Hopkins Hospital: a history of sex reassignment

By RACHEL WITKIN | May 1, 2014

Editor’s note: this article makes several misleading claims. It does not properly contextualize psychologist John Money ’ s forced sexual reassignment surgery of David Reimer. It also implies that sexual reassignment surgery was introduced in the 1960s, though procedures took place earlier in the 1900s.

The News-Letter regrets these errors.

In 1965, the Hopkins Hospital became the first academic institution in the United States to perform sex reassignment surgeries. Now also known by names like genital reconstruction surgery and sex realignment surgery, the procedures were perceived as radical and attracted attention from The New York Times and tabloids alike. But they were conducted for experimental, not political, reasons. Regardless, as the first place in the country where doctors and researchers could go to learn about sex reassignment surgery, Hopkins became the model for other institutions. But in 1979, Hopkins stopped performing the surgeries and never resumed.

In the 1960s, the idea to attempt the procedures came primarily from psychologist John Money and surgeon Claude Migeon, who were already treating intersex children, who, often due to chromosome variations, possess genitalia that is neither typically male nor typically female. Money and Migeon were searching for a way to assign a gender to these children, and concluded that it would be easiest if they could do reconstructive surgery on the patients to make them appear female from the outside. At the time, the children usually didn’t undergo genetic testing, and the doctors wanted to see if they could be brought up female.

“[Money] raised the legitimate question: ‘Can gender identity be created essentially socially?’ ... Nurture trumping nature,” said Chester Schmidt, who performed psychiatric exams on the surgery candidates in the 60s and 70s.

This theory ended up backfiring on Money, most famously in the case of David Reimer, who was raised as a girl under the supervision of Money after a botched circumcision and later committed suicide after years of depression.

However, at the time, this research led Money to develop an interest in how gender identities were formed. He thought that performing surgery to match one’s sex to one’s gender identity could produce better results than just providing these patients with therapy.

“Money, in understanding that gender was — at least partially — socially constructed, was open to the fact that [transgender] women’s minds had been molded to become female, and if the mind could be manipulated, then so could the rest of the body,” Dana Beyer, Executive Director of Gender Rights Maryland, who came to Hopkins to consider the surgery in the 70s, wrote in an email to The News-Letter .

Surgeon Milton Edgerton, who was the head of the University’s plastic surgery unit, also took an interest in sex reassignment surgery after he encountered patients requesting genital surgery. In 2007, he told Baltimore Style : “I was puzzled by the problem and yet touched by the sincerity of the request.”

Edgerton’s curiosity and his plastic surgery experience, along with Money’s interest in psychology and Migeon’s knowledge of plastic surgery, allowed the three to form a surgery unit that incorporated other Hopkins surgeons at different times. With the University’s approval, they started performing sex reassignment surgeries and created the Gender Identity Clinic to investigate whether the surgeries were beneficial.

“This program, including the surgery, is investigational," plastic surgeon John Hoopes, who was the head of the Gender Identity Clinic, told The New York Times in 1966. “The most important result of our efforts will be to determine precisely what constitutes a transsexual and what makes him remain that way.”

To determine if a person was an acceptable candidate for surgery, patients underwent a psychiatric evaluation, took gender hormones and lived and dressed as their preferred gender. The surgery and hospital care cost around $1500 at the time, according to The New York Times .

Beyer found the screening process to be invasive when she came to Hopkins to consider the surgery. She first heard that Hopkins was performing sex reassignment surgeries when she was 14 and read about them in Time and Newsweek .

“That was the time that I finally was able to put a name on who I was and realized that something could be done,” she said. “That was a very important milestone in my consciousness, in understanding who I was.”

When Beyer arrived at Hopkins, the entrance forms she had to fill out were focused on sexuality instead of sexual identity. She says she felt as if they only wanted to consider hyper-feminine candidates for the surgery, so she decided not to stay. She had her surgery decades later in 2003 in Trinidad, Colo.

“It was so highly sexualized, which was not at all my experience, certainly not the reason I was going to Hopkins to consider transition, that I just got up and left, I didn’t want anything to do with it,” she said. “No one said this explicitly, but they certainly implied it, that the whole purpose of this was to get a vagina so you could be penetrated by a penis.”

Beyer thinks that it was very important that the transgender community had access to this program at the time. However, she thinks that the experimental nature of the program was detrimental to its longevity.

“It had negative consequences because when it was done it was clearly experimental,” she said. “Our opponents were able to use the experimental nature of the surgery in the 60s and the 70s against us.”

By the mid-70s, fewer patients were being operated on, and many changes were made to the surgery and psychiatry departments, according to Schmidt, who was also a founder of the Sexual Behaviors Consultation Unit (SBCU) at the time. The new department members were not as supportive of the surgeries.

In 1979, SBCU Chair Jon Meyer conducted a study comparing 29 patients who had the surgery and 21 who didn’t, and concluded that those who had the surgery were not more adjusted to society than those who did not have the surgery. Meyer told The New York Times in 1979: “My personal feeling is that surgery is not proper treatment for a psychiatric disorder, and it’s clear to me that these patients have severe psychological problems that don’t go away following surgery.”

After Meyer’s study was published, Paul McHugh, the Psychiatrist-in-Chief at Hopkins Hospital who never supported the University offering the surgeries according to Schmidt, shut the program down.

Meyer’s study came after a study conducted by Money, which concluded that all but one out of 24 patients were sure that they had made the right decision, 12 had improved their occupational status and 10 had married for the first time. Beyer believes that officials at Hopkins just wanted an excuse to end the program, so they cited Meyer’s study.

“The people at Hopkins who are naturally very conservative anyway … decided that they were embarrassed by this program and wanted to shut it down,” she said.

A 1979 New York Times article also states that not everyone was convinced by Meyer’s study and that other doctors claimed that it was “seriously flawed in its methods and statistics and draws unwarranted conclusions.”

However, McHugh says that it shouldn’t be surprising that Hopkins discontinued the surgeries, and that he still supports this decision today. He points to Meyer’s study as well as a 2011 Swedish study that states that the risk of suicide was higher for people who had the surgery versus the general population.

McHugh says that more research has to be conducted before a surgery with such a high risk should be performed, especially because he does not think the surgery is necessary.

“It’s remarkable when a biological male or female requests the ablation of their sexual reproductive organs when they are normal,” he said. “These are perfectly normal tissue. This is not pathology.”

Beyer, however, cites a study from 1992 that shows that 98.5 percent of patients who underwent male-to-female surgery and 99 percent of patients who underwent female-to-male surgery had no regrets.

“It was clear to me at the time that [McHugh] was conflating sexual orientation and the actual physical act with gender identity,” Beyer said.

However, she thinks that shutting down the surgeries at Hopkins actually helped more people gain access to them, because now the surgeries are privatized.

“Paul McHugh did the trans community a very big favor … Privatization [helps] far more people than the alternative of keeping it locked down in an academic institution which forced trans women to jump through many hoops.”

Twenty major medical institutions offered sex reassignment surgery at the time that Hopkins shut its program down, according to a 1979 AP article.

Though the surgeries at Hopkins ended in 1979, the University continued to study sexual and gender behavior. Today, the SBCU provides consultations for members of the transgender community interested in sex reassignment surgery, provides patients with hormones and refers patients to specialists for surgery.

The Hopkins Student Health and Wellness Center is also working toward providing transgender students necessary services as a plan benefit under the University’s insurance plan once the student health insurance plan switches carriers on Aug. 15.

“We are hopefully working towards getting hormones and other surgical options covered by the student health insurance,” Demere Woolway, director of LGBTQ Life at Hopkins, said. “We’ve done a number of trainings for the folks over in the Health Center both on the counseling side and on the medical side. So we’ve done some great work with them and I think they are in a good place to be welcoming and supportive of folks.”

Schmidt does ongoing work to provide the Hopkins population with transgender services, and says he would like for Hopkins to start performing sex reassignment surgeries again. But Chris Kraft, the current co-director of the SBCU, says that this is not feasible today, as no academic institution provides these surgeries since not enough people request them.

“It is unfortunate that no medical schools in the country have faculty who are trained or able to provide surgeries,” he wrote in an email to The News-Letter . “All the best surgeons work free-standing, away from medical schools. If we had surgeons who could provide the same quality services as the other surgeons in the country, then it would make sense to provide these services. Sadly, few physicians are willing to make gender surgery a priority in their careers because gender patients who go on to surgery are a very small population.”

Beyer, however, does not think that the transgender community needs Hopkins to reinstate its program, and that there are currently enough options available.

“We’re way, way past that,” she said. “It’s no longer the kind of procedure that needs an academic institution to perform research and development.”

Though she finds the way that Hopkins treated its sex reassignment patients in the 60s and 70s questionable, she thinks that the SBCU has been a great resource for the transgender community.

“Today those folks are wonderful people,” Beyer said. “They’re very helpful. They’re the go-to place up in Baltimore. They’ve done a lot of good for a lot of people. They’ve contributed politically as well to passage of gender identity legislation in Maryland and elsewhere.”

The Maryland Coalition for Trans Equality’s Donna Cartwright said that the transgender community does not have enough resources available to them. She said offering surgery at a nearby academic institution could provide more support to the community.

“Generally, the medical community needs to be better educated on trans health care and there should be greater availability [of sex reassignment surgery],” she said. “I think it would be good if there was an institution in the area that did provide health care, including surgery.”

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He made this town the world’s ‘sex-change capital,’ but he’s not honored here

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If you’re looking for evidence that this little-known Western outpost was, for 41 years, known as the world’s “sex-change capital,” be prepared to look a long time.

Dr. Stanley Biber, the colorful country surgeon whose pioneering work made “going to Trinidad” a euphemism for gender confirmation surgery, has been dead since 2006 . His decades of work, which brought medical pilgrims from around the world to this heavily Catholic former coal-mining town, is not commemorated in any way at Mt. San Rafael Hospital, where Biber and his protege, Dr. Marci Bowers, performed an estimated 6,000 gender surgeries between 1969 and 2010.

For the record:

11:15 a.m. Sept. 12, 2019 A photo caption on an earlier version of this article misidentified Trinidad, Colo., Councilman Joe Bonato as Joe Binato.

Biber’s widow removed a display of her late husband’s medical artifacts from the hospital’s lobby when she moved to Pueblo after his death and says her discussions with the city about naming a nearby street after Biber went nowhere.

You’ll find no statue, memorial, or even a plaque marking Biber’s long career as the man who brought Trinidad world renown, though many other significant chapters in local history are acknowledged by plaques along downtown sidewalks. It wasn’t until May, more than 13 years after the surgeon’s death, that the local museum included any mention of his work in an exhibit space that celebrates practically every other detail of the city’s remarkable Old West history.

Until then, the only evidence that Biber even existed were the personal stories shared by many in town whose lives he touched, his unremarkable gravestone in the Jewish section of Trinidad’s Masonic Cemetery and the outdated directory of tenants painted on the gray marble wall of a side entrance to Main Street’s First National Bank building, where for decades a creaky elevator carried patients up to his musty private office for pre-surgery consultations. The building’s hand-lettered mention of “Dr. S.H. Biber, P.C., Surgeon” among the fourth-floor tenants remains today simply because no one has bothered to remove it.

But at this pivot point in American history, when many still struggle to reconcile a binary view of gender with the proven complexities of a gender spectrum, and hard-fought rights advances for transgender Americans are being rolled back, the story of Stanley Biber and his pioneering work in Trinidad offers a remarkable tale of insight and compassion. Why did a doctor in a Western frontier town embrace transgender men and women decades ahead of most, and dedicate a good deal of his professional life to easing their pain? And why does he remain such an unknown figure?

Some say the story began during Biber’s service as a battlefield surgeon in the Mobile Army Surgical Hospital during the Korean War.

Korea is where Biber thrived on the challenge of innovating as his patients’ conditions changed, and he developed a reputation for tirelessness by performing 37 consecutive surgeries before passing out from exhaustion. He honed his surgical dexterity trying to save soldiers whose lower bodies were devastated by wounds to reproductive organs, bowels and urinary tracts.

World & Nation

How Stanley Biber, a pioneer in gender confirmation surgery, won over the Sisters of Charity

When he started the gender-confirmation surgeries in Trinidad, Colo., Dr. Stanley Biber had some explaining to do — to the nuns who worked as patient advocates.

Sept. 12, 2019

While Biber excelled at a number of things during his postwar life — he claimed to have missed the U.S. Olympic weightlifting team “by 20 pounds,” and even into his 80s would roll up his sleeves over his biceps to show off his guns — he seized the chance to become a small-town doctor. In 1954, he joined the staff of a clinic the United Mine Workers opened in Trinidad, where about half of Las Animas County’s 26,000 residents lived. At that point, Biber was the only general surgeon in town.

“He was so dedicated there,” says Ella Mae Biber, the fourth of his five wives and to whom he was married for 23 years. “He delivered so many babies, did everybody’s surgery, and everybody trusted him tremendously. He loved everyone in Trinidad. You don’t see doctors commit to their patients anymore. He took care of them from birth to death, in most cases.”

Column One is a showcase for compelling storytelling from the Los Angeles Times.

• More Column One stories

It’s hard to find a local today who’s not eager to share a personal story of the time Biber set a broken bone, did an unexpected minor surgery during an office visit, or delivered them squalling into the world. Trinidad resident Dick Hamman credits Biber with saving his father’s life when he developed peritonitis after an appendix rupture: “You put a scalpel in his hand and he was Michelangelo.”

The moment that would change Biber’s life, the reputation of his adopted hometown and the lives of thousands of transgender patients “came to him by accident,” his stepdaughter Kelly Biber recalls. “It just kind of walked into his office one day.”

His visitor was a social worker with whom Biber had often consulted. As Biber recounted in various interviews, the red-haired woman lingered a moment after their meeting ended. Eventually, she asked a question: “Can you do my surgery?”

The ever-confident Biber agreed without discussion, boasting, “Of course I can do your surgery. What do you want done?”

His visitor explained that she was a “transsexual woman.” Biber pondered her words before finally asking: “What’s that?”

It was 1969. Sure, he knew about the Christine Jorgensen case, in which a former Army clerk had gender confirmation surgery in 1952. Who didn’t? But at the time, the term “transsexual” was hardly part of the cultural vocabulary.

You put a scalpel in his hand and he was Michelangelo.

— TRINIDAD RESIDENT DICK HAMMAN

At the time Johns Hopkins Hospital in Baltimore was an American center of what then was called “sex-change surgery.” Biber called a plastic surgeon there who had done about 13 such operations, seven of which were what Biber described as “simple penectomies” similar to the operation done on Jorgensen. That surgeon eventually sent Biber a set of rudimentary hand-drawn diagrams showing the basic technique for deconstructing genitalia and reconstructing it into a vagina. Biber looked over the drawings and called the social worker back. “Well, I’ve never done one, but if you want to do it, I think we can do it.”

In the late 1960s, transgender men and women seeking surgical relief didn’t have many options, but many were emboldened by an evolving culture. Susan Stryker, author of the 2008 book “Transgender History,” describes the dawning of a “transgender aesthetic” back then — gender-bending entertainers such as rock artists the New York Dolls and David Bowie were finding their way into the American mainstream — that signaled a changing relationship between appearance and assigned sex. It was the start of a cultural conversation about how gender might be more complicated than a simple binary choice: male or female?

But back when many of the better-known university clinics were following the lead of influential Johns Hopkins, which decided to drop its program in 1979, Biber’s fledgling specialty practice in Trinidad was a revelation to many transgender men and women. Here was a skilled surgeon at a real hospital who offered them help, dignity and hope — all with a dose of unflappable confidence, and without judgment. That combination was enough to coax people to Trinidad from thousands of miles away.

During his peak years, Biber was doing up to four gender confirmation surgeries a week, for both male-to-female and female-to-male patients.

His work made headlines — and occasionally drew the attention of self-righteous outsiders. In 1999, for example, members of the staunchly anti-LGBTQ Kansas-based Westboro Baptist Church arrived to picket what its news release for the event described as “Satan’s physician” and the town it called the “anteroom to Hell.” Feature stories about Biber appeared in this newspaper and other national media, and TV show host Geraldo Rivera and his camera crew documented a surgery.

As far as his grandkids are concerned, Biber’s fame peaked with a 2005 episode of the animated TV series “South Park” called “Mr. Garrison’s Fancy New Vagina,” in which the show’s transgender schoolteacher character travels to see Dr. Biber at the Trinidad Medical Center to undergo surgery. (Biber was not pleased, his stepdaughter Kelly recalls.)

Trinidad as the world’s “sex-change capital” didn’t register much in the mainstream American consciousness during those years, and was easy to dismiss as a distant signal emanating from the middle of nowhere. Transgender men and women were unfamiliar to many, and hard to fathom. But day in and day out, week after week, month after month, year after year, the pilgrims came to Trinidad.

They continued to do so until Biber’s age and inability to get liability insurance caught up with him in 2003. He died three years later after training Bowers, a transgender surgeon from Seattle he hoped would carry on his practice in Trinidad. But where Biber was low-key, humble and a longtime member of the community who once served on the county commission, Bowers’ silver Porsche Boxster and more active courtship of publicity — she starred in a short-lived BBC reality TV series called “Sex Change Hospital” — didn’t sit well with the locals and hospital officials. She left town in 2010, moving her practice to Burlingame, Calif., and bringing that peculiar chapter in the city’s history to a close.

The local invisibility of the man behind such a vital chapter in transgender history may be less a result of social taboo, discrimination and local politics than Trinidad’s own identity struggle over the years.

Founded in 1862 after rich coal seams were discovered in the region, Trinidad was a company town by 1910. Colorado Fuel and Iron operated the largest steel mills in the West, as well as dozens of mines, coke ovens, transportation lines and other infrastructure needed to support the local industry. CF&I created countless small communities for the mine workers it recruited from throughout Europe, believing that people who spoke different languages were less likely to organize into unions to improve the often brutal working conditions.

Those conditions led to a notorious chapter in labor history just a few miles north of Trinidad. Union leader Louis Tikas, 12 children and two women were among 20 who died in a violent company crackdown known as the Ludlow Massacre in spring 1914 — a conflict that former Colorado state historian William J. Convery has called “the bloodiest civil insurrection in American history since the Civil War.”

Trinidad transformed itself after the coal industry began to fade in the 1920s, achieving a strange sort of prosperity, or at least notoriety, during Prohibition when Chicago mobster Al Capone and his family hid out in Trinidad and nearby Aguilar by blending in with the Italian immigrant families who continued to call the city home.

Those various bursts of 20th century prosperity left Trinidad with lavish hotels, a Carnegie Library, an opera house, churches and the oldest continuously active synagogue in the state. A 2012 promotional film produced in part by the county Chamber of Commerce referred to Trinidad as “the Victorian jewel of southern Colorado” without ever mentioning the medical claim to fame for which today it remains best known.

Lately, Trinidad, nicknamed “Weed Town, USA” by High Times magazine, has become a center of legal marijuana cultivation and sale. Thanks to its proximity to several states where recreational marijuana remains illegal, it has attracted thousands of pot tourists, and the town of fewer than 10,000 residents now boasts more than 30 such enterprises. The revenue is helping with long overdue upgrades to Trinidad’s infrastructure, but the weed boom may not last forever, especially if neighboring New Mexico legalizes in the coming years.

City leaders already are looking beyond the current green rush. They envision a community as a center for arts and recreation. The city and two conservation groups just announced a $25-million plan to buy Fisher’s Peak, the iconic stair-stepped mesa that overlooks the city, as well as the 30-plus square miles of wilderness around it. They plan to build a hiking trail from the center of town up to the peak, and the state announced plans this week to turn it into a state park.

During my spring 2018 visit to research a book about Biber’s career in Trinidad, the surgeon’s legacy was entirely invisible. But 15 months later, there was talk of plans to celebrate him, a local 1960s-era commune called Drop City and other creative renegades in a new counterculture museum, which would be part of the new state-orchestrated creative district taking shape in the heart of downtown. It’s still in the planning stages, but the possibility suggests a growing acknowledgment that Biber has perhaps been overlooked.

The most telling sign that the city is getting more comfortable with Biber’s place in local history is the oblique line in the new Trinidad Visitor’s Guide. Without mentioning Biber by name, it reads: “For half a century, Trinidad welcomed thousands of individuals seeking to become who they were born to be.” It touts that as evidence that Trinidad is “one of the most welcoming places in the country.”

Trinidad native Jay Cimino, chief executive of the Phil Long chain of car dealerships and a benefactor behind a number of town initiatives, also foresees a spot for Biber in the gallery of Trinidad’s “champions” he’s assembling in the entry hall of the refurbished Champions Building on Commercial Street, not far from Biber’s old office. That gallery celebrates not just local sports and education heroes, but also those who “championed” people who needed help. Those include Sister Blandina Segale of the Sisters of Charity religious order who helped establish Colorado’s first school district in Trinidad and whose kindness is said to have helped persuade Billy the Kid to change his outlaw ways.

“It certainly would not surprise me if Biber’s name came up as a champion in this town,” Cimino says. “It should.”

You may have concluded that Biber’s obscurity suggests a certain discomfort among locals with his chosen area of specialty, or a continuing marginalization of that important history for transgender Americans. Most locals will tell you that you’re wrong, including one you might expect to take Biber’s exclusion as a personal slight.

Trinidad City Councilwoman Michelle Miles came to Trinidad for gender confirmation surgery in 2005 and later made it her home — one of the few medical pilgrims to have done so. She says Trinidad is just not the kind of place that goes around putting up statues and plaques.

“The only commemorations I see are Coal Miners Memorial Park and the Coal Miners Museum, because that’s such a rich part of Trinidad’s tradition,” says Miles, a former Wall Street investment banker. “So are Billy the Kid, Bat Masterson, Doc Holliday and Kit Carson. Good lord, it’s an incredible history.”

Like so much of the West, Miles says, her adopted hometown is “driven by people looking for an opportunity to re-identify themselves, and reinvent themselves.” Even today, she adds, identity politics don’t matter much in Trinidad. “I don’t run on trans issues when I run for City Council. I just live my life. People casually know that I’m trans, and it’s OK, and that’s just the way it is.”

Paula Manini, former director of the Trinidad History Museum, voiced the same sentiment to NPR in a piece that aired shortly after Biber’s death: “You know that Western attitude … what you do is your business, what I do is mine, and that’s it.”

Dawn DiPrince, chief operating officer of History Colorado, the state historical society, was the lead developer of the “Borderlands” exhibit that opened in May at the Trinidad History Museum. It focuses on how land management and healthcare changed in that frontier region after the Treaty of Guadalupe Hidalgo moved the Mexican border farther south and made southern Colorado part of the United States. The exhibit includes a small tribute to Biber — apparently the first of its kind in town — that includes the old camera the surgeon used to take pre-surgery photographs of his transgender patients. During a recent visit, museum director Kirby Stokes proudly showed off the Biber display.

“When you operate in a borderland, you’re on the margins, not close to the centers of power,” DiPrince says. “If you exist on the margins, there’s a lot of opportunity for invention and creativity, and for taking risks that people would not ordinarily do if they were more in the mainstream.”

DiPrince says Biber was a perfect example of that, and suggests that remote Trinidad may have been one of the few places where his transgender work could flourish the way it did.

Miles says a more elaborate Biber tribute may someday follow, but notes that the town only recently erected a statue honoring Greek immigrant and labor hero Louis Tikas, the first victim in the Ludlow Massacre, and only then because his family and the Denver chapter of the Foundation of Hellenism of America commissioned it. Miles says Trinidad’s only involvement was to have city workers build a pedestal along Main Street.

That public commemoration of Tikas took 104 years.

Former Los Angeles Times Magazine senior editor Martin J. Smith has just completed a nonfiction book titled “Post-Op: Untold Stories of Life, Love, and Transformation from the World’s Unlikely ‘Sex-Change Capital.’ ”

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November 16, 2016

A History of Transgender Health Care

As the stigma of being transgender begins to ease, medicine is starting to catch up

By Farah Naz Khan

This article was published in Scientific American’s former blog network and reflects the views of the author, not necessarily those of Scientific American

An estimated 1.4 million Americans, close to 0.6 percent of the population of the United States, identify as transgender. And, today, the topic of transgender health care is more widely discussed than ever before. Despite this, lost in the shuffle between conversations about equal access to bathrooms and popular culture icons is the history of a piece of modern medicine that should no longer remain so elusive. To be willing to embrace the future of this pivotal area of healthcare, it is imperative to understand the piecemeal roots and evolution of transgender medicine.

Magnus Hirschfeld, a German physician who could easily be considered the father of transgender health care, coined the term “ transvestite ” in 1918 at his Institute for Sexual Science in Berlin. Defining transvestism as the desire to express one’s gender in opposition to their defined sex, Hirschfeld and his colleagues used this now antiquated label as a gateway to the provision of sex changing therapies and as a means to protect his patients. Going against the grain, Hirschfeld was one of the first to offer his patients the means to achieve sex change, either through hormone therapy, sex change operations, or both.

In a time when his contemporaries aimed to “cure” transgender patients of their alleged mental affliction, Hirschfeld’s Adaptation Theory supported those who wanted to live according to the gender they felt most aligned with, as opposed to the gender that their sex obligated them to abide by. Much of the history of the institute’s early works were destroyed in the wake of the Nazi book burnings in 1933, but as far as history can prove, Hirschfeld’s institute was the first to offer gender reassignment surgery.

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In 1922, Hirschfeld performed castration on Dora Richter , one of the institute’s employees who later went on to complete her sex reassignment in 1931 with further surgeries at the institute. The institute's most famous patient was arguably Danish painter Lili Elbe (born Einar Wegener) whose life story has been fictionalized in the popular film The Danish Girl . Starting in 1930, Elbe had five surgeries performed as part of her male-to-female transition. Unfortunately, Elbe died from infection-related complications of her final surgery in 1931.

World War II and Nazi Germany forced Hirschfeld into exile and this along with the destruction of his Berlin institute, minimal further advancements were made by his group at that time. Pioneering influences in America began emerging in the 1940s, including Dr. Alfred Kinsey , the biologist who founded the Institute for Sex Research at Indiana University in 1947 (now known as the Kinsey Institute). Kinsey was one of the first to use the term transsexual in his gender studies, and he helped introduce America to a concept that for some reason still seems foreign to many today despite its obvious place in history for years.

The first American to undergo a sex change operation was Christine Jorgensen, who brought significant attention to the transgender revolution in America when her story hit New York Times headlines in 1952. Jorgensen’s willingness to publicly tell her story helped bring a face to the growing transgender revolution in the states, but at the time the lack of quality transgender healthcare in the U.S. meant that Jorgensen had to travel to Denmark to get the treatment she needed.

Following Jorgensen's successful treatment in Denmark by Dr. Christian Hamburger , many other transgender Americans wrote to Hamburger for similar treatment. Hamburger referred these individuals to endocrinologist Henry Benjamin, who had offices in both New York City and San Francisco. Benjamin had been studying transgender issues since at least the 1950s , but it was his 1966 book The Transsexual Phenomenon that left the most indelible impact on American transgender healthcare.

Having spent time with Hirschfeld and his Berlin institute, Benjamin supported the same principles, that those who feel their sex to be discordant from their gender deserve treatment in the form of hormonal therapy and reassignment surgeries and not psychotherapy for a “cure.” In covering such a highly stigmatized health care issue at the time of its publication, The Transsexual Phenomenon laid the foundation for modern transgender healthcare.

Over a decade later, a 1979 study out of Johns Hopkins called sex reassignment surgeries into question by suggesting that psychosocial outcomes in transgender patients who underwent reassignment surgery were not better than those who went without surgery. Despite criticism and a nod to flaws in its methodology, the study led to the closure of the Johns Hopkins Gender Identity Clinic and an end to the sex reassignment surgeries offered there.

In an attempt to standardize care in response to this study’s accusations, the Henry Benjamin International Gender Dysphoria Association, now better known as the World Professional Association for Transgender Health (WPATH), created the first version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Now in its seventh iteration, the WPATH Standards of Care provide guidance on everything from hormone therapy to surgical interventions and everything in between.

Despite all of the apparent advancements in transgender health care noted above, the 1980 addition of “ gender identity disorder ” to the American Psychiatric Association’s (APA) third Diagnostic and Statistical Manual (DSM-3) seemed like a giant leap backwards, but this controversial move actually helped transgender individuals gain access to an often impenetrable healthcare system. Slowly, but surely, strides were made towards removing the notion of “ disorder ” in the context of gender identity, and with the release of the DSM-5 in 2013, gender identity disorder was replaced with the diagnosis “gender dysphoria.”

Destigmatization of this diagnosis was a major milestone for transgender individuals in America, and further strides were achieved when a government appeals board in 2014 ruled that Medicare must cover surgery for gender transitions, overturning a policy that had been in place since the 1980s. Given that the surgeries are no longer experimental in nature and that the updated WPATH standards of care reference many studies which have proven the beneficial effects of sex reassignment therapy for transgender individuals, this ruling was a long time coming.

Gone are the days of rudimentary surgeries and experimental therapies, because we now know what works. And in an effort to make treatment of transgender patients even easier and more accessible for providers everywhere, in 2009, the Endocrine Society put together brief clinical practice guidelines . These guidelines cover diagnosis, treatment, and preventive care needs for transgender patients, while also drawing attention to the potential risks associated with gender transition therapies.

Modern transgender healthcare encompasses all of the above, along with a shift in focus on patient care. Our transgender patients are like all of our other patients, and their gender identity is just one facet of their overall identity. Multidisciplinary clinics that focus on key issues for transgender patients are important, because they can provide access to subspecialists who can focus on hormone therapy, fertility questions, mental health, etc—but equally important is the understanding that transgender patients need to be able to see a primary care physician for their common cold without fear of stigma due to their gender identity. We can only hope that these widespread stigmas and hesitancies will dissipate with time, because as history has clearly proven, where there is a will, there most certainly is a way.

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Chapter 1:  A History of Transgender and Gender Diverse Health Care: From Medical Mistreatment to Gender-Affirmative Health Care

Farah Naz Khan

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Introduction, key figures in the history of transgender and gender diverse health care.

• HISTORY OF TREATMENTS IN TRANSGENDER AND GENDER DIVERSE HEALTH CARE
• TRANSGENDER AND GENDER DIVERSE HEALTH CARE TODAY
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This chapter describes the history of transgender and gender diverse (TGD) health care in the United States ( Figure 1-1 ). This historical context is essential to understanding both the progress made in the United States health care system and current gaps that need to be addressed in the clinical care of TGD populations.

Timeline of key events in the history of transgender health care. (Used with permission from Farah Naz Khan)

The founder of transgender health care could easily be German physician Magnus Hirschfeld. Hirschfield coined the now obsolete term “transvestite” in 1910 in his work, Die Transvestiten. 1 Although this term is no longer considered acceptable, Hirschfeld’s definition of the term provided an initial framework for articulating the experience of gender diversity: “It is the urge to present and conduct oneself in the outer raiment of the sex to which a person does not belong—as regards the visible sexual organs.” 2 In a time when his contemporaries aimed to “cure” gender diverse patients, Hirschfeld developed and implemented “adaptation therapy” at his Institute for Sexual Science in Berlin, to help patients live “according to their nature.” 2 Hirschfeld even worked with the legal advisor of his institute to support name changes, something which is a struggle to achieve even in many modern medical records. 2 It would also not be a stretch to align Hirschfeld’s pluralist sexual theory with the modern-day concepts of gender and sexual diversity. In his theory, Hirschfeld posited that there are a multitude of gender expressions, all of mixed “absolute male” and “absolute female” characteristics. 2

Much of the institute’s history was lost in the wake of Nazi book burnings in 1933, 3 but as far as history demonstrates, Hirschfeld likely was the first to offer gender-affirming surgery when he performed castration in 1922 on one of his employees who identified as a woman. 2 Perhaps the institute’s most famous patient was Danish painter Lili Elbe (born Einar Wegener), whose life story was fictionalized for the Hollywood film The Danish Girl . Hirschfeld performed castration on Elbe before she sought other gender-affirming surgeries elsewhere in Germany. 4 After the institute’s destruction, Hirschfeld was forced into exile, and very few additional advancements in TGD health care were made by his group. 2

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Introduction

The historic and cultural diversity of gender, biological underpinnings of gender identity, history of modern gender-affirming medical treatment, history of gender-affirming medical treatment in adolescents, changing prevalence of trans identities and the rise of nonbinary identification, legislative and social dynamics, conclusions, statement of ethics, conflict of interest statement, funding sources, author contributions, data availability statement, the evolution of adolescent gender-affirming care: an historical perspective.

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Jeremi M. Carswell , Ximena Lopez , Stephen M. Rosenthal; The Evolution of Adolescent Gender-Affirming Care: An Historical Perspective. Horm Res Paediatr 29 November 2022; 95 (6): 649–656. https://doi.org/10.1159/000526721

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While individuals have demonstrated gender diversity throughout history, the use of medication and/or surgery to bring a person’s physical sex characteristics into alignment with their gender identity is relatively recent, with origins in the first half of the 20th century. Adolescent gender-affirming care, however, did not emerge until the late 20th century and has been built upon pioneering work from the Netherlands, first published in 1998. Since that time, evolving protocols for gender-diverse adolescents have been incorporated into clinical practice guidelines and standards of care published by the Endocrine Society and World Professional Association for Transgender Health, respectively, and have been endorsed by major medical and mental health professional societies around the world. In addition, in recent decades, evidence has continued to emerge supporting the concept that gender identity is not simply a psychosocial construct but likely reflects a complex interplay of biological, environmental, and cultural factors. Notably, however, while there has been increased acceptance of gender diversity in some parts of the world, transgender adolescents and those who provide them with gender-affirming medical care, particularly in the USA, have been caught in the crosshairs of a culture war, with the risk of preventing access to care that published studies have indicated may be lifesaving. Despite such challenges and barriers to care, currently available evidence supports the benefits of an interdisciplinary model of gender-affirming medical care for transgender/gender-diverse adolescents. Further long-term safety and efficacy studies are needed to optimize such care.

The relatively recent recognition of diversity of “gender identity” – one’s inner sense of self as male or female or somewhere on the gender spectrum – in the current culture belies its long-standing presence in cultures diverse and ancient. “Transgender” (sometimes referred to as “gender incongruence”) is defined as a marked and persistent incongruence between an individual’s experienced gender and their sex designated at birth. Transgender is often used as an umbrella term to encompass all gender identities that are not the same as the birth-assigned gender (typically based on the sex designated at birth) but may also be used specifically for a binary gender identification.

As our understanding of gender has been evolving over time, so has the language used to describe gender. Throughout this manuscript, the authors have primarily used the terminology of the present day, though historical descriptions will contain language that is clearly outdated. We have chosen to use these terms only to maintain the historical perspective in this context.

Though it may seem that transgender as a concept is a recent phenomenon, there are both ancient and diverse examples that underscore the understanding that humans have experienced gender as beyond the set of cultural norms assigned to them based on their genitals. In Greek and Roman mythology, there are legends of deities who defy traditional concepts of gender; the most famous may be Hermaphroditus, a son born of Hermes and Aphrodite. When the nymph Salmacis fell in love with him, their forms became merged, with the god depicted as having male genitalia with breasts and a more feminine body shape [1, 2]. Norse mythology gives us the notorious shape and sex shifting Loki, who was known for his trickery, appearing at times in a female form when it suited his purpose [1]. Several Indigenous North American tribes have long-standing recognition and language for gender and/or sexual minority-identified individuals that often signified a third gender, or a combination of male and female. Though the designation and roles varied among tribes, the term “two-spirit” was coined in 1990 during the international LGBT Native American Gathering and attributed to Elder Maya Laramee [3, 4]. This term is not specific to any one tribe or any one group of individuals but encompasses any indigenous member with gender-diverse identification or same-sex attraction.

John Money, a New Zealand psychologist and faculty member in pediatrics at Johns Hopkins University beginning in the early 1950s, and co-founder of the Gender Identity Clinic at that university, promoted the concept that gender identity was influenced by “social learning and memory” in conjunction with biological factors [5]. However, a widely publicized case described in a book by John Colapinto published in 2000 lends strong support to the concept that gender identity is not primarily learned [6]. This book focused on a failed circumcision in an 8-month-old male resulting in loss of the penis, leading Money to advise the family to castrate the infant and raise him as a girl [6]. The child never accepted a female gender identity, became severely depressed, and changed gender to male during adolescence. He later committed suicide [6]. In subsequent years, evidence in support of biological underpinnings to gender identity development has continued to emerge, derived primarily from three biomedical disciplines: genetics, endocrinology, and neurobiology [7].

Starting in the late 1970s, heritability of being transgender was suggested from studies describing concordance of gender identity in monozygotic twin pairs and in father-son and brother-sister pairs [8, 9]. In the largest twin study evaluating gender identity, in which at least one member of a twin pair was transgender, there was a much greater likelihood that the other member of the twin pair was also transgender if they were identical versus nonidentical (but same sex) twins [ 10 ]. Attempts to identify polymorphisms in candidate genes that might be more prevalent in transgender versus cisgender individuals have been inconsistent. In particular, a 2009 study from Japan did not find any significant associations of transsexualism with polymorphisms in five candidate genes (encoding the androgen receptor, CYP19, ER-alpha, ER-beta, and the progesterone receptor) [ 11 ]. However, a 2019 study in 380 transgender women and 344 cisgender male controls demonstrated an over-representation of several allele combinations involving the androgen receptor in transgender women [ 12 ]. A subsequent study using whole-exome sequencing in a relatively small number of transgender males ( n = 13) and transgender females ( n = 17) demonstrated 21 variants in 19 genes that were associated with previously described estrogen receptor-activated pathways of sexually dimorphic brain development [ 13 ]. An association between polymorphisms in the estrogen receptor alpha gene promoter and a transgender male identity has also been reported [ 14 ].

The vast majority of transgender individuals do not have an intersex condition or any associated abnormality in sex steroid production or responsiveness [7]. However, studies in a variety of intersex conditions have informed our understanding of the potential role of hormones, particularly prenatal and early postnatal androgens, in gender identity development [7]. For example, several studies of 46,XX individuals with virilizing congenital adrenal hyperplasia caused by 21-hydroxylase deficiency demonstrated a greater prevalence of a transgender identity outcome (female to male) compared to the general population [ 15-17 ]. One such study published in 2006 demonstrated a relationship between severity of congenital adrenal hyperplasia and gender identity outcome, where 7% of patients with the severe salt-wasting form had gender dysphoria or a male gender identity, while no gender dysphoria was seen in any of the less severely affected individuals [ 16 ]. Studies in a variety of other hormonal and nonhormonal intersex conditions support a role of prenatal and/or postnatal androgens in gender identity development [7]. However, in 2011, a case report in a 46,XY individual with complete androgen insensitivity and a male gender identity challenged the concept that androgen receptor signaling is required for male gender identity development [ 18 ].

Neuroimaging studies that aim to understand the neurobiology of gender identity indicate that some sexually dimorphic brain structures are more closely aligned with gender identity than with physical sex characteristics in transgender adults prior to treatment with gender-affirming hormones [ 19-21 ]. A similar trend was reported in studies of gray matter in youth with gender dysphoria [ 22 ]. In 2021, an MRI study in transgender adults, also prior to treatment with gender-affirming sex hormones, found that transgender people have a unique brain phenotype “rather than being merely shifted towards either end of the male-female spectrum” [ 23 ]. Notably, in both transgender adolescents and adults, several functional brain studies looking at responses to odorous compounds or mental rotation tasks demonstrated that patterns typically observed to be sexually dimorphic were more closely aligned with gender identity than with physical sex characteristics, even before treatment with gender-affirming sex hormones [ 24-26 ].

Though individuals have demonstrated gender diversity throughout history, the use of medication and/or surgery is relatively recent with origins in Germany in the first half of the 20th century and is credited to the pioneering work of Magnus Hirschfeld. The institution he founded, “Institut für Sexualwissenschaft (the Institute for Sexual Science)” in Berlin (1922), paved the way for the use of hormones and surgery [ 27 ]. In Hirschfeld’s study of what he named “sexual intermediaries,” he recognized that people may be born with a nature contrary to their assigned gender. In cases where the desire to live as the opposite sex was strong, he thought science ought to provide a means of transition. Innovative for his time, he argued that a person may be born with characteristics that did not fit into heterosexual or binary categories and supported the idea that a “third sex” existed naturally [ 27 ]. The first documented case of genital surgery was performed at the institute on Dorchen Richter in 1922 with orchiectomy and then 1931 with penectomy and vaginoplasty [ 27, 28 ]. Notable patients, including Lili Elbe (born Einar Wegener), the patient on whom the movie “The Danish Girl” is based, underwent a series of operations including transplant of both ovaries and a uterus [ 29 ].

This clinic would be a century old if it had not fallen victim to Nazi ideology and Hitler’s mission to rid Germany of Lebensunwertes Leben, or “lives unworthy of living.” What began as a sterilization program ultimately led to the extermination of millions of Jews, Gypsies, Soviet, and Polish citizens, as well as homosexuals and transgender people. When the Nazis came for the institute in 1933, Hirschfeld had fled to France. Troops swarmed the building and created a bonfire that engulfed more than 20,000 of his books, some of them rare copies that had helped provide a history for transgender people [ 27 ].

In the 1950s, German-American physician Harry Benjamin (1885–1986) introduced the term “transsexuality,” defining a “transsexual” person as someone who identifies in opposition to their “biological sex” [ 30 ]. Harry Benjamin graduated cum laude from medical school in Tübingen, Germany, in 1912. He moved to New York City in 1914 to study tuberculosis, but over time, he became known as a geriatrician, endocrinologist, and sexologist [ 31 ]. He did not treat his first transgender patient until he was in his 60s, and his colleagues described him as follows: “Being a true physician, Benjamin treated all these patients as people and by respectfully listening to each individual voice, he learned from them what gender dysphoria was about” [ 32 ]. Notably, he did not describe “transsexualism” as a psychological problem, but as a biological condition that could be treated with hormone or surgical therapy [ 31 ]. He treated over 1,500 patients, and in 1966, he published the first medical textbook in this field, “The Transsexual Phenomenon” [ 33 ]. His work was very influential, and he became known as “The Father of Transsexualism” [ 31, 32 ].

Following World War II, gender-affirming treatment in the USA was limited to wealthy patients who could afford to travel to Europe, though they did so at great risk given the laws in several states outlawing “cross-dressing” [ 34 ]. Christine Jorgensen (1926–1989) brought visibility to transgender patients, having undergone medical and surgical transition in Europe after she had served time in the US military as a male [ 35 ].

Influenced by Dr. Benjamin Harris’ “The Transsexual Phenomenon” [ 33 ], Johns Hopkins Hospital in Baltimore became the first academic institution in the USA to offer gender-affirming surgery [ 36 ]. Soon after, at least another 8 academic institutions opened transgender programs throughout the 1960–1970s (University of Minnesota, University of Washington, Northwestern/Cook County Health in Chicago, Stanford University, Cleveland Clinic, University of Colorado, Baptist Medical Center in Oklahoma City, and Washington University in St. Louis) [ 37 ].

Toward the end of the 1970s, however, most transgender programs closed access to new patients. These closures were done quietly out of public view, and the causes were often not disclosed [ 37 ]. At Johns Hopkins Hospital, Paul McHugh became the Chair of Psychiatry in 1975. From the moment he was hired, McHugh openly stated he intended to stop gender-affirming surgery at this hospital [ 38 ]. Under his leadership, another Johns Hopkins psychiatrist, Dr. Jon Meyer, published a study of 50 patients which concluded that gender-affirming surgery did not provide “objective” benefit for transgender individuals [ 39 ]. This publication led to the sudden closure of the clinic in 1979 [ 36 ]. Interestingly, John Money, who believed that gender could be learned and who co-founded the Johns Hopkins gender clinic, publicly expressed opposition to Meyer’s conclusions of his study [ 36 ].

The program at the Baptist Medical Center in Oklahoma City had been functioning since 1973. However, in 1977, its existence was brought to the attention of the Board of Directors of the Baptist General Convention of Oklahoma. This led to a 54-2 vote by the Board of Directors at the Baptist Medical Center to close the program. Physicians who passionately advocated to continue this practice issued a joint statement saying, “If Jesus Christ were alive today, undoubtedly he would render help and comfort to the transsexual” [ 37 ].

It is thought that publicity around the Meyer paper [ 39 ] from Johns Hopkins played a role in an escalation of closure of other clinics [ 37 ]. Despite these closures, academic interest in the field led to the foundation of the Harry Benjamin Gender Dysphoria Association in 1979 [ 40 ]. This association had the goal of organizing professionals who were interested in the “study and care of transsexualism and gender dysphoria.” It has since been renamed the World Professional Association for Transgender Health (WPATH) and has evolved into a large international multidisciplinary organization that provides Standards of Care for the treatment of transgender/gender-diverse (TGD) adolescents and adults [ 41 ].

In 1980, “transsexualism” and “gender identity disorder of childhood” were both recognized as illnesses in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders [ 42 ]. In 2013, the term “gender identity disorder” was replaced by “gender dysphoria in children” and “gender dysphoria in adolescents and adults” to diagnose and treat those transgender individuals who felt distress at the mismatch between their gender identities and their bodies, with the American Psychiatric Association stating that “it is important to note that gender nonconformity is not in itself a mental disorder” [ 43 ].

In 2019, the World Health Organization International Classification of Diseases version 11 replaced International Classification of Diseases-10’s “transsexualism” and “gender identity disorder of children” with “gender incongruence of adolescence and adulthood” and “gender incongruence of childhood,” respectively [ 44 ]. Gender incongruence was moved out of the “Mental and behavioral disorders” chapter into a new chapter, entitled “Conditions related to sexual health” [ 44 ]. This reflects current perspective that TGD identities are not mental health illnesses and that classifying them as such can cause significant stigma.

Providers in the Netherlands recognized the importance of preventing progression of a gender incongruent puberty by using a gonadotropin hormone-releasing hormone analog (GnRHa) followed by treatment with either testosterone or estrogen to bring physical characteristics into alignment with a patient’s gender identity [ 45, 46 ]. This approach was first published by Drs. Cohen-Kettenis and van Goozen in 1998 in a case report of an adolescent treated with GnRHa by Dr. Henriette A. Delemarre-van de Waal (though not named in the publication) (Dr. Sabine E. Hannema , personal communication) [ 47 ]. Under the direction of Dr. Peggy Cohen-Kettenis, the first program geared to treating adolescents with gender dysphoria was established in the Netherlands [ 45 ]. Initially based on the guidelines of adult transgender treatment established by the Harry Benjamin Society and adapted to adolescents, patients first underwent comprehensive psychological assessment to establish a diagnosis of gender dysphoria (then called “gender identity disorder”) and then initiated treatment with GnRH agonists (GnRHa) typically at Tanner 2–3 to pause pubertal development [ 45, 46 ]. The time spent under pubertal suppression would be used to further explore gender identity prior to committing to either estrogen or testosterone and their physical effects. This intervention with a GnRHa would also be somewhat of a diagnostic aid in that if it eased the distress; it was reasonable to correlate the distress with gender dysphoria as a primary cause. This was followed by hormone therapy around age of 16 years and then gender-affirming genital surgery at 18 years or later [ 45, 46, 48 ]. The “Dutch Protocol” [ 49 ] was adapted by practitioners internationally, though it was not until pediatric endocrinologist and adolescent medicine pediatrician Dr. Norman Spack , having traveled to Amsterdam to observe the clinic there, established the first formal US program geared specifically to transgender adolescents at Boston Children’s Hospital: the Gender Management (subsequently replaced with Multispecialty) Service program in 2007 [ 50 ]. It should be noted that adolescents there and elsewhere across the USA had been treated outside of a structured program [ 50 ]. Clinical protocols at Gender Management Service were derived from direct observation, adaptation of the Dutch program, and a May 2005 consensus meeting (the Gender Identity Research and Education Society) and expanded upon previous guidelines from the Standards of Care of the WPATH and those from the Royal College of Psychiatrists [ 46, 51, 52 ].

The Endocrine Society guidelines, with input from the Pediatric Endocrine Society, the European Society for Paediatric Endocrinology, the European Society for Endocrinology, and WPATH, were first published in 2009 and recommended the use of GnRHa as a treatment for selected adolescents [ 53 ]. Pubertal suppression could be initiated when the individual reached Tanner 2 or 3, followed by gender-affirming hormones at age of 16 years. Subsequent standards of care and clinical practice guidelines published by WPATH (SOC 8 in 2022) [ 41 ], the University of California San Francisco in 2016 [ 54 ], and the Endocrine Society (updated in 2017) [ 55 ] continued to recommend treatment for adolescents starting with pubertal suppression at Tanner 2 and 3, with consideration of gender-affirming sex hormones in some adolescents younger than 16 years old (on a case-by-case basis) who had demonstrated strong and persistent gender dysphoria. Of note, the WPATH SOC 8 does not list minimum age requirements for gender-affirming medical care [ 41 ].

In 2014, a published resource guide providing contact information showed that there were 32 US and 2 Canadian programs available to treat TGD adolescents [ 56 ]. As of March 2022, there were about 60 recognized pediatric/adolescent multidisciplinary gender programs in the USA, though smaller programs and individual offices probably also provide care [ 57 ]. Some programs have been closed for political reasons with potentially dire consequences for both patients and practitioners [ 58 ].

Worldwide, the prevalence of people declaring a gender identity that is different from that assigned at birth has risen sharply as the recognition of gender diversity, and its social acceptance has increased. Early estimates of prevalence for those seeking hormonal treatment are notable for relatively low prevalence and a heavy predominance of birth-assigned males. In 1968, two authors published estimates demonstrating this trend. In the USA, Pauly cited 1:100,000 birth-assigned males and 1:400,000 birth-assigned females [ 59 ]. In Sweden, the estimate again favored the birth-assigned males at 1:37,000 and birth-assigned females at 1:103,000 [ 60 ]. By the mid-80s, numbers had risen with a similar ratio of birth-assigned males at 1:18,000 and birth-assigned females at 1:54,000 [ 61 ]. The same year, authors in Singapore reported much higher numbers of 1:2,900 and 1:8,300 birth-assigned males and females, respectively [ 62 ]. The Williams Institute of the University of California Los Angeles School of Law has tracked prevalence of transgender identification in the USA. A report from 2022 (based on data from 2017, 2019, and 2020) revealed that the prevalence of adults in the USA who identified as transgender has remained stable at around 0.5% of the population, or 1.3 million adults. However, the percentage of trans-identified youth (ages 13–17) had notably increased in recent years from 0.7% to 1.4% of the population [ 63 ]. Recent reports have also noted a rise in nonbinary gender identification and a reversal in the sex ratio of adolescents presenting for gender-affirming care from a predominance of those designated male at birth to a predominance of individuals designated female at birth. In 2017, a large adolescent multidisciplinary survey noted that 63% of the presenting patients were birth-assigned females [ 64 ].

Since 2016, many US states and European countries have introduced laws that restrict transgender youth from accessing gender-affirming care, team sports, and restrooms that are consistent with their gender identity [ 65 ]. Simultaneously, numerous reputable national and international academic medical societies have openly and repeatedly stated their opposition to these laws. This includes the Pediatric Endocrine Society [ 66, 67 ], the Endocrine Society [ 68, 69 ], the American Academy of Pediatrics [ 70 ], the American Medical Association [ 71 ], the United States Professional Association for Transgender Health [ 72 ], the American Association for Child and Adolescent Psychiatry [ 73 ], and in a united statement, also the American Psychiatric Association, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, and the American Osteopathic Association [ 74 ].These societies have stated that these bills are discriminatory and cause harm to the mental health of transgender youth. Despite this, some bills have passed successfully [ 65 ].

While there is a long-standing history acknowledging the existence of human gender diversity, the history of gender-affirming medical care for adolescents, in particular, is relatively brief. Evolving protocols for gender-diverse adolescents, first pioneered in the Netherlands, have been incorporated into clinical practice guidelines and standards of care published by the Endocrine Society and WPATH, respectively, and have been endorsed by major medical and mental health professional societies around the world. Notably, however, while there has been increased acceptance of gender diversity in some parts of the world, transgender adolescents and those who provide them with gender-affirming medical care, particularly in the USA, have been caught in the crosshairs of a culture war, with the risk of preventing access to care that published studies have indicated may be lifesaving. Despite such challenges and barriers to care, currently available evidence supports the benefits of an interdisciplinary model of gender-affirming medical care for transgender adolescents. Further long-term safety and efficacy studies are needed to optimize such care.

Not applicable as this is a historical report and not a report of research.

Jeremi M. Carswell, Ximena Lopez, and Stephen M. Rosenthal declare no conflicts of interest.

This work has not received any funding or financial support.

Jeremi M. Carswell, Ximena Lopez, and Stephen M. Rosenthal contributed equally to the writing of the manuscript. Jeremi Carswell and Ximena Lopez are the co-first authors, and Stephen M. Rosenthal is the senior and corresponding author.

There were no data generated for this report.

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A brief history of transgender issues

Whenever, wherever on this earth, we will find people who contravene gender boundaries. I'm not talking about the small ways of 'queering' gender, such as the lesbian separatists who wore dungarees in the 1970s. I mean the big ways: not just queering gender, but crossing gender. I mean the drive that makes people risk so much to represent a gender they feel is theirs, and yet is very different to the social, cultural and legal expectations of their birth sex. Whatever culture, country or epoch you choose to research, you will find a history of individuals who, if they lived now, we might now refer to as trans people.

We must be careful with our words. 'Transvestite' originated in 1910 from the German sexologist Magnus Hirschfeld, who would later develop the Berlin Institute where the very first 'sex change' operations took place. 'Transsexual' was not coined until 1949, 'transgender' not until 1971, and 'trans' (a very British term) not until 1996. According to the Oxford English Dictionary, the first use of 'androgyne' was recorded in 1552, but it has only been in the last 10 years that people have claimed it for themselves to describe a state of being in-between, or having both genders. 'Polygender' is a late 1990s Californian invention used to describe a state of being multiple genders.

This is by no means a complete list of words used by people to describe themselves. Long before Hirschfeld, other cultures had developed their own terminologies to describe 'trans' people. From the Hijra of India, to the Fa'afafine of Polynesia, the ladyboys and the tomboys of Thailand, and the Takatāpui of New Zealand, there are a myriad of words used by trans people to describe themselves.

The start of the scientific study of sexology

In 1885 the Criminal Law Act was passed in the UK, which made all homosexual behaviour illegal. Similar laws were put in place throughout Europe during this period. When homosexuality was made illegal, those suspected of it - such as Oscar Wilde - could face imprisonment and hard labour for up to two years. People who cross-dressed became easy targets of the law because they were associated, in the public mind, with homosexual subculture.

One of the first public trials for transvestite behaviour was that of Ernest (Stella) Boulton, and Fred (Fanny) Park, arrested in 1870 for indecent behaviour. The authorities based the prosecution on their transvestism and their soliciting of men as women, rather than the act of sodomy. No conviction could be obtained on these grounds and they were acquitted of the charge of conspiracy to commit a felony by cross-dressing. One of the largest organisations for transvestite men in the US today is the Boulton and Park Society.

As a result of these laws, people who were trans sought out doctors who could cure them and a whole new field in medicine developed: sexology. The first sexologist who took a special interest in the sexual impulses of trans individuals was probably Krafft-Ebbing (1840-1902), professor of psychiatry at Vienna. His Psychopathia Sexualis was published from 1877 to after his death. Krafft-Ebbing constantly endeavoured to give clearer classifications to the behaviours and individual histories of his patients.

Through the work of the early sexologists such as Krafft-Ebbing and Hirschfield, transsexuality became a recognized phenomenon available for study, discussion and treatment. Throughout the 1920s and 30s medical provision was very sparse, but still transsexual people managed to find doctors who would help them. At Hirschfield's infamous clinic, the first sex change operations were performed by Dr Felix Abraham: a mastectomy on a trans man in 1926, a penectomy on his domestic servant Dora in 1930, and a vaginoplasty on Lili Elbe, a Danish painter, in 1931. The surgery was not easy, and Lily died less than two years later from complications.

In the UK, Michael (formerly Laura) Dillon managed to obtain gender reassignment treatment during the war. In the late 1940s he even had a penis constructed by the plastic surgeon Sir Harold Gilles, who later became famous for his work with burns victims. Michael Dillon trained and worked as a ship's doctor until he was outed by the Sunday Express in 1958. He withdrew to India where he became a Buddhist monk and writer until his death in 1962.

Modern transsexuality

Eight years before Dillon was outed, Christine Jorgensen, a former American GI, returned from Denmark where she had undergone the first of several operations as part of her gender reassignment, and the media picked up on the story. Overnight she became a news sensation, and was undoubtedly the most famous transsexual figure in the 20th century. She was beautiful, blond, and everybody's idea of the 'all-American girl'. As one obituary put it:

"Her very public life after her 1952 transition and surgery was a model for other transsexuals for decades. She was a tireless lecturer on the subject of transsexuality, pleading for understanding from a public that all too often wanted to see transsexuals as freaks or perverts ... Ms Jorgensen's poise, charm, and wit won the hearts of millions."

[Candice Brown Elliot, 1999]

Almost immediately, Jorgensen's psychiatrist in Denmark, Dr Hamburger, started receiving letters and in 1953 he published a paper, The desire for change of sex as shown by personal letters from 465 men and women. Suddenly medical professionals realised that these were not exceptional cases: there was a whole swathe of people who were unhappy because their gender role did not match their body.

The endocrinologist Harry Benjamin (who had trained at Hirschfield's clinic) set up a clinical practice, first in New York and later in San Francisco. He trained a new generation of psychiatrists and psychotherapists in the treatment of transsexual people. The former head of research at the UK Gender Identity Clinic at Charing Cross hospital, Professor Richard Green, trained with Benjamin. When Benjamin published the first major textbook on the subject, The Transsexual Phenomenon, in 1966, gender reassignment was still the subject of extensive social stigma both publicly and in the medical world.

Over 40 years later, some of that stigma remains, but it is widely accepted that the only successful treatment for transsexual people is hormone therapy and surgical reassignment. A 1999 appeal court decision in the UK has confirmed this view, and it is an area of medicine that is gradually gaining respectability.

Transsexual people have also become much more visible. Jan (James) Morris, the travel writer, was the Times reporter on the 1953 expedition that conquered Everest; Billy (Dorothy) Tipton was one of the best jazz saxophonists of the 1950s; Wendy (Walter) Carlos is famous for her Switched on Bach recordings. And, of course, many of us now know a trans colleague, neighbour, family member or friend.

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The evolution of transgender surgery

Affiliations.

• 1 Department of Radiology, Collegium Medicum, School of Medicine, University of Warmia and Mazury, Olsztyn, Poland.
• 2 Department of Anatomy, University of Warmia and Mazury, Olsztyn, Poland.
• 3 Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies.
• 4 Department of Pediatric Urology, UPMC Hamot, Erie, Pennsylvania.
• PMID: 29732618
• DOI: 10.1002/ca.23206

An estimated 1.4% of the population worldwide has been diagnosed with Gender Dysphoria, as defined by the Diagnostic and Statistical Manual of Mental Disorders. Gender reassignment, which holistically encompasses psychotherapy, hormonal therapy and genital and nongenital surgeries, is considered the most effective treatment for transgender nonconforming patients afflicted with gender dysphoria. Little research is currently available identifying the psychosocial needs of the transgender population and their access to preventative and primary care during this transitioning process. This article presents an overview of the evolution and current approaches to genital surgical procedures available for both male-to-female, as well as female-to-male gender-affirmation surgeries. Clin. Anat. 31:878-886, 2018. © 2018 Wiley Periodicals, Inc.

Keywords: gender dysphoria; transgender persons; transsexualism.

© 2018 Wiley Periodicals, Inc.

Publication types

• Historical Article
• Attitude of Health Personnel
• Diagnostic and Statistical Manual of Mental Disorders
• Gender Dysphoria / history
• Gender Dysphoria / psychology
• Gender Dysphoria / surgery*
• History, 16th Century
• History, 17th Century
• History, 18th Century
• History, 19th Century
• History, 20th Century
• Sex Reassignment Procedures / history
• Sex Reassignment Procedures / methods*
• Sex Reassignment Procedures / trends
• Standard of Care
• Transgender Persons / history
• Transgender Persons / psychology
• Transsexualism / history

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• News and Views

The history of gender reassignment surgeries in the UK

For Pride Month, we are recognising the plastic surgeons who pioneered gender reassignment surgeries (GRS) in the UK. Gender reassignment surgery, also known as gender confirmation surgery or gender affirmation surgery, is a sub-speciality within plastic surgery, developed based on reconstructive procedures used in trauma and in congenital malformations. The specific procedures used for GRS have only been practised in the last 100 years.

Over the last decade, there has been an increase in society acknowledgement and acceptance of gender diverse persons. This catalysed an increase in referrals to gender identity clinics and an increase in the number of gender affirmation surgeries. GRS help by bringing fulfilment to many people who experience gender dysphoria. Gender dysphoria - a distress caused by the incongruence of a person's gender identity and their biological sex, drives the person to seek medical or surgical intervention to align some or all of their physical appearance with their gender identity. Patients with gender dysphoria experience higher rates of psychiatric disorders such as depression and anxiety. Gender-affirming medical intervention tends to resolve the psychiatric disorders that are a direct consequence of gender dysphoria.

Norman Haire (1892-1952) was a medical practitioner and a Sexologist. In his book, The Encyclopaedia of Sexual Knowledge (1933), he describes the first successful GRS. His patient, Dora Richter underwent 3 procedures reassigning from male to female between 1922-1931. The procedures included a vaginoplasty (surgical procedure where a vagina is created).

In the UK, gender reassignment surgeries were pioneered by Sir Harold Gillies. Harold Gillies is most famous for the development of a new method of facial reconstructive surgery, in 1917. During the Second World War, he organized plastic surgery units in various parts of Britain and inspired colleagues to do the same, training many doctors in this field. During the war, Gillies performed genital reconstruction surgeries for wounded soldiers.

British physician Laurence Michael Dillon (born Laura Maude Dillon) felt that they were not truly a woman. Gillies performed the first phalloplasty (surgery performed to construct the penis) on Dillon in 1946. In transitioning from female to male, Dillon underwent a total of 13 operations, over a period of 4 years.

Roberta Cowell (born Robert Marshall Cowell) is the first known Brit to undergo male to female GRS. After meeting Dillon and becoming close, Dillon operated illegally on Cowell. The operation helped her obtain documents confirming that she was intersex and have her birth gender formally re-registered as female. The operation that helped her transition was forbidden as it was considered “disfiguring” of a man who was otherwise qualified to serve in the military. Consequently, Gillies, assisted by American surgeon Ralph Millard performed a vaginoplasty on Roberta in 1951. The technique pioneered by Harold Gillies remained the standard for 40 years.

Gillies requested no publicity for his gender affirmation work.  In response to the objections received from his peers, he replied that he was satisfied by the patient's written sentiments: “To Sir Harold Gillies, I owe my life and my happiness”. “If it gives real happiness,” Gillies wrote of his procedures, “that is the most that any surgeon or medicine can give.” These words highlight the importance of plastic surgery in the mental wellbeing of transgender patients.

The BAPRAS Collection and Archive has an extraordinary assembly of fascinating archive and historical surgical instruments dating from 1900. Visit https://www.bapras.org.uk/professionals/About/bapras-archive or email [email protected] for more information.

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The Gender Reassignment Controversy

When people opt for surgery, are they satisfied with the outcome.

Posted March 16, 2018 | Reviewed by Ekua Hagan

In an age of increasing gender fluidity, it is surprising that so many find it difficult to accept the gender of their birth and take the drastic step of changing it through surgery. What are their motives? Are they satisfied with the outcome?

Gender may be the most important dimension of human variation, whether that is either desirable, or inevitable. In every society, male and female children are raised differently and acquire different expectations, and aspirations, for their work lives, emotional experiences, and leisure pursuits.

These differences may be shaped by how children are raised but gender reassignment, even early in life, is difficult, and problematic. Reassignment in adulthood is even more difficult.

Such efforts are of interest not just for medical reasons but also for the light they shed on gender differences.

The first effort at reassignment, by John Money, involved David Reimer whose penis was accidentally damaged at eight months due to a botched circumcision.

The Money Perspective

Money believed that while children are mostly born with unambiguous genitalia, their gender identity is neutral. He felt that which gender a child identifies with is determined primarily by how parents treat it and that parental views are shaped by the appearance of the genitals.

Accordingly, Money advised the parents to have the child surgically altered to resemble a female and raise it as “Brenda.” For many years, Money claimed that the reassignment had been a complete success. Such was his influence as a well-known Johns Hopkins gender researcher that his views came to be widely accepted by scholars and the general public.

Unfortunately for Brenda, the outcome was far from happy. When he was 14, Reimer began the process of reassignment to being a male. As an adult, he married a woman but depression and drug abuse ensued, culminating in suicide at the age of 38 (1).

Money's ideas about gender identity were forcefully challenged by Paul McHugh (2), a leading psychiatrist at the same institution as Money. The brunt of this challenge came from an analysis of gender reassignment cases in terms of both motivation and outcomes.

Adult Reassignment Surgery Motivation

Why do people (predominantly men) seek surgical reassignment (as a woman)? In a controversial take, McHugh argued that there are two main motives.

In one category fall homosexual men who are morally uncomfortable about their orientation and see reassignment as a way of solving the problem. If they are actually women, sexual interactions with men get redefined as heterosexual.

McHugh argued that many of the others seeking reassignment are cross-dressers. These are heterosexual men who derive sexual pleasure from wearing women's clothing. According to McHugh, surgery is the logical extreme of identifying with a female identity through cross-dressing.

If his thesis is correct, McHugh denies that reassignment surgery is ever either medically necessary or ethically defensible. He feels that the surgeon is merely cooperating with delusional thinking. It is analogous to providing liposuction treatment for an anorexic who is extremely slender but believes themselves to be overweight.

To bolster his case, McHugh looked at the clinical outcomes for gender reassignment surgeries.

Adult Reassignment Results

Anecdotally, the first hurdle for reassignment is how the result is perceived by others. This problem is familiar to anyone who looked at Dustin Hoffman's depiction of a woman ( Tootsie ). Diligent as the actor was in his preparation, his character looked masculine.

For male-to-female transsexuals, the toughest audience to convince is women. As McHugh reported, one of his female colleagues said: “Gals know gals, and that's a guy.”

According to McHugh, although transsexuals did not regret their surgery, there were little or no psychological benefits:

“They had much the same problems with relationships, work, and emotions, as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled (2)”.

Thanks to McHugh's influence, gender reassignment surgeries were halted at Johns Hopkins. The surgeries were resumed, however, and are now carried out in many hospitals here and around the world.

What changed? One likely influence was the rise of the gay rights movement that now includes transgender people under its umbrella and has made many political strides in work and family.

McHugh's views are associated with the religious right-wing that has lost ground in this area.

Transgender surgery is now covered by medical insurance reflecting more positive views of the psychological benefits.

Aspirational Surgery

Why do people who are born as males want to be women? Why do females want to be men? There seems to be no easy biological explanation for the transgender phenomenon (2).

Transgender people commonly report a lifelong sense that they feel different from their biological category and express satisfaction after surgery (now called gender affirmation) that permits them to be who they really are.

The motivation for surgical change is thus aspirational rather than medical, as is true of most cosmetic surgery also. Following surgery, patients report lower gender dysphoria and improved sexual relationships (3).

All surgeries have potential costs, however. According to a Swedish study of 324 patients (3, 41 percent of whom were born female) surgery was associated with “considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”

1 Blumberg, M. S. (2005). Basic instinct: The genesis of behavior. New York: Thunder's Mouth Press.

2 McHugh, P. R. (1995). Witches, multiple personalities, and other psychiatric artifacts. Nature Medicine, 1, 110-114.

3 Dhejne, S., Lichtenstein, P., Boman, M., et al. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study of Sweden . Plos One.

Nigel Barber, Ph.D., is an evolutionary psychologist as well as the author of Why Parents Matter and The Science of Romance , among other books.

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LGBTQ Movement Suffers Blow Due to New Study Challenging Push for Child Gender Transition

Posted: April 19, 2024 | Last updated: April 19, 2024

New Longitudinal Study Questions Child Gender Transition

The research found that 78% of participants experienced no gender dissatisfaction. 19% saw decreased dissatisfaction over time, while only 2% reported increased dissatisfaction.

Permanent physical alterations like hormones and surgeries pose risks that can't be undone if gender feelings change. Strict guidelines are needed to limit irreversible treatments for minors.

Conservative Concerns

Some conservatives argue this study confirms skepticism about facilitating childhood gender transitions. Patrick Brown of the Ethics and Public Policy Center said, "This study provides even more reason to be skeptical towards aggressive steps to facilitate gender transition in childhood and adolescence."

He argued that for most, "prudence and caution, rather than a rush towards permanent surgeries or hormone therapies, will be the best approach for teenagers struggling to make sense of the world and their place in it."

Ongoing Debate

This research comes as more US children receive medical interventions to transition gender. The implications intensify an ongoing debate about treatment for transgender youth.

While some see medical intervention as lifesaving, others view it as harmful or unnecessary for those still developing a sense of identity. Additional research on child development and gender is needed to determine best practices.

Research Finds Most Gender Dysphoria Resolves by Adulthood

The study, published in Archives of Sexual Behavior, followed more than 2,700 individuals from preteen years into their mid-twenties.

Over 15 years, researchers periodically surveyed participants about their gender identity feelings, finding a notable decline in dissatisfaction as they grew up.

Change of Mind By Age 25

Initially, around 11% of children expressed some form of gender discontent. However, by age 25, only 4% still felt this way, showing that these feelings often resolve during maturation.

The Tracking Adolescents' Individual Lives Survey studied 2,772 people to explore gender dissatisfaction, defined as unhappiness with the assigned birth gender, and connections to self-image, mental health, and sexual orientation.

History of The LGBTQ Movement

In the 1950s, the Mattachine Society and the Daughters of Bilitis became two of the first major LGBTQ organizations in the U.S., raising awareness of the challenges faced by gay and lesbian people.

The Stonewall Riots of 1969 marked a pivotal moment that catalyzed the modern LGBTQ rights movement. When police raided the Stonewall Inn, a popular gay bar in New York City, patrons fought back, leading to days of protest.

Fighting Discrimination and Demanding Recognition and Rights

Activists campaigned to remove homosexuality from the American Psychiatric Association's list of mental illnesses and passed laws prohibiting discrimination based on sexual orientation.

The AIDS epidemic of the 1980s and 1990s spurred further action as activists fought for research funding and policies to address the health crisis.

Multiple Wins For The LGBTQ Movement

By the 2000s and 2010s, the LGBTQ movement achieved several hard-fought victories. The U.S. Supreme Court struck down laws prohibiting same-sex relationships and marriage.

However, discrimination and barriers to equality persist. The movement continues campaigning for laws banning discrimination in employment, public accommodations, and medical care.

The History of The Transgender Movement and Transgender Children

For centuries, some cultures have recognized the concept of a "third gender" for those who did not fit into the typical gender binary.

The first known gender reassignment surgery took place in Germany in the 1930s. In the 1950s and 1960s, doctors began performing "sex change" operations with increasing frequency.

When Did The Transgender Movement Join The LGBTQ Movement

The transgender movement joined the broader LGBTQ movement in the 1970s and 1980s. Up until that point, the gay rights and transgender rights movements had operated mostly separately.

While the histories of the gay and transgender movements are distinct, they also share many parallels. Bringing the two movements into a broader LGBTQ coalition has helped amplify both causes and build strength in numbers.

The Rise of the Trans Rights Movement

The transgender rights movement began gaining momentum in the 1970s. Activists fought for legal protections and against pathologization by medical and psychiatric institutions.

The 21st century has seen significant strides in transgender rights and recognition. More children can now socially and medically transition at younger ages with the support of their families and doctors.

Wait-and-See Approach

The study suggests a "wait-and-see" approach may be most prudent for kids with gender dysphoria. Rather than rushing into hormone therapy or surgery, adopting a cautious stance allows a child's gender identity to unfold and solidify during adolescence and young adulthood.

The researchers found that 78% of participants experienced no change in gender dissatisfaction over 15 years, while 19% saw a decrease. Only 2% exhibited an increase.

Risks of Early Transition

While some children require medical support, more research is needed to determine appropriate criteria and guidelines. Irreversible physical changes and life-long hormone dependence are serious considerations, especially for minors.

Critics argue that minors are not capable of providing fully informed consent for such impactful procedures. They posit that transition may do more harm than good for kids whose gender dysphoria would have otherwise resolved naturally over time.

Study Methodology and Key Findings

The study utilized data from the Tracking Adolescents' Individual Lives Survey (TRAILS), an ongoing research project launched in 2001 to explore mental health and social development in individuals from early adolescence into young adulthood.

Participants were surveyed at multiple points, starting at ages 11 and 12 and again at ages 19 and 25. Researchers evaluated responses related to gender identity and dissatisfaction to determine how feelings changed over time.

Key Findings in the Netherlands Study

The study's findings highlight three distinct trajectories for gender identity development. Most participants (78%) reported no feelings of gender dissatisfaction.

However, 19% indicated decreasing dissatisfaction over time, while 2% showed increasing dissatisfaction into young adulthood. Females were more likely to report gender dissatisfaction, which was also linked to poorer self-esteem and higher rates of emotional and conduct problems.

Reaction From Transgender Advocates and Critics

Transgender advocates argue that the research does not account for the mental health benefits of gender transition for those who continue to experience gender dysphoria into adulthood.

"For the minority of trans youth who need it, medical intervention can be lifesaving," said Rachel Percelay of the Transgender Law Center. However, critics point out that the findings highlight the risks of premature medical intervention for children and the need for stricter guidelines.

Exercise Extreme Caution When It Comes to Transitioning Minors

"This evidence suggests we should exercise extreme caution before facilitating medical transition among minors," said Dr. Paul Hruz, a pediatric endocrinologist. Hruz emphasized that most children with gender dysphoria will overcome these feelings naturally by adulthood if given proper counseling and support.

"Rather than immediately proceeding to hormonal and surgical interventions, helping children feel comfortable with their biological sex may be a preferable approach for many," he said.

Study Authors Acknowledge The Study Does Have Limitations

The authors acknowledge the study's limitations, including the uncertainty of whether participants were representative of the general population and the possibility of response bias.

However, they maintain that the results provide valuable insight into the developmental course of gender identity in children and adolescents.

The findings suggest that gender dysphoria in children and adolescents may be more transient than previously thought and highlight the need to consider alternative treatment approaches, such as counseling, before pursuing medical intervention.

A Need To Take A Pause With Minors Seeking Transitioning

"This research should give pause to reckless practitioners who are too quick to prescribe irreversible treatments to minors dealing with issues of gender identity," wrote Michelle Cretella, executive director of the American College of Pediatricians.

Cretella called for an end to "unscientific gender ideology" that promotes medical intervention for children. In contrast, advocates argue that treatment should remain patient-centered. "For trans youth, the most important thing is that they have autonomy and self-determination over their own bodies and health care," Percelay said.

Alternatives to Medical Interventions for Gender Dysphoric Youth

Medical intervention for children and teenagers with gender dysphoria has become increasingly controversial, especially in light of new research indicating these feelings may subside over time.

As an alternative to hormone therapy and gender reassignment surgery, some experts recommend a "watchful waiting" approach for youth. This involves ongoing counseling and mental health support without medical intervention.

Counseling and Therapy Before Medical Intervention

For many gender dysphoric youth, counseling and therapy can help address underlying issues contributing to distress over their gender identity and provide coping strategies to manage these feelings.

Both individual and family counseling are effective for some children. Counseling may explore how societal gender expectations influence a child's views of themselves and address anxiety, depression, or trauma that could exacerbate feelings of gender dysphoria.

Social Transitioning as An Alternative

Some families find that allowing a child to socially transition to their preferred gender through a change in hairstyle, clothing, and name can help alleviate distress.

This approach allows a child to explore their gender identity before pursuing medical intervention. Social transitioning is considered a reversible approach, unlike hormone therapy or surgery.

Gender Dissatisfaction Declines into Adulthood

This extensive research provides compelling evidence that gender transition surgeries should not be rushed into for children and teenagers struggling with gender identity issues.

As the study shows, feelings of gender dissatisfaction naturally decline for most individuals as they mature into adulthood. With up to 80% of children resolving their gender uncertainty in the long run, these findings emphasize the need for extreme care when considering permanent medical procedures for minors.

Protecting Children Should Be A Priority

For youth navigating complex gender feelings, evidence-based guidelines must be implemented to avoid irreversible physical changes that most grow to regret.

This research delivers a sobering reality check on the spiking popularity of childhood gender transitions. Medical interventions come with permanent, life-altering consequences that this study proves are unnecessary for the large majority questioning their gender.

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Sweden passes disputed gender reassignment law

Stockholm (AFP) – Sweden's parliament on Wednesday passed a controversial law lowering the minimum age to legally change gender from 18 to 16 and making it easier to get access to surgical interventions.

Issued on: 17/04/2024 - 18:15

The law passed with 234 votes in favour and 94 against in Sweden's 349-seat parliament.

While the Nordic country was the first to introduce legal gender reassignment in 1972, the proposal, aimed at allowing so-called "self-identification" and simplifying the procedure, sparked an intense debate in the country.

The debate has also weakened conservative Prime Minister Ulf Kristersson's standing, after he admitted to caving into pressure from party members on the issue.

"The great majority of Swedes will never notice that the law has changed, but for a number of transgender people the new law makes a large and important difference," Johan Hultberg, an MP representing the ruling conservative Moderate Party, told parliament.

Beyond lowering the age, the new legislation is aimed at making it simpler for a person to change their legal gender.

"The process today is very long, it can take up to seven years to change your legal gender in Sweden," Peter Sidlund Ponkala, president of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights (RFSL), told AFP.

Two new laws will go into force on July 1, 2025: one regulating surgical procedures to change gender, and one regulating the administrative procedure to change legal gender in the official register.

No diagnosis needed

People will be able to change their legal gender as of age 16, though those under 18 will need the approval of their parents, a doctor, and the National Board of Health and Welfare.

A diagnosis of "gender dysphoria" -- where a person may experience distress as a result of a mismatch between their biological sex and the gender they identify as -- will no longer be required.

Surgical procedures to transition would, like now, be allowed from the age of 18, but would no longer require the Board of Health and Welfare's approval.

The removal of ovaries or testes will however only be allowed from the age of 23, unchanged from today.

A number of European countries have already passed laws making it easier for people to change their legal gender.

Citing a need for caution, Swedish authorities decided in 2022 to halt hormone therapy for minors except in very rare cases, and ruled that mastectomies for teenage girls wanting to transition should be limited to a research setting.

Sweden has seen a sharp rise in gender dysphoria cases.

The trend is particularly visible among 13- to 17-year-olds born female, with an increase of 1,500 percent since 2008, according to the Board of Health and Welfare.

While tolerance for gender transitions has long been high in the progressive and liberal country, political parties across the board have been torn by internal divisions over the new proposal, and academics, health care professionals and commentators have come down on both sides of the issue.

'Deplorable'

A poll published this week suggested almost 60 percent of Swedes oppose the proposal, while only 22 percent back it.

Far-right Sweden Democrats leader Jimmie Akesson lamented the result of Wednesday's vote.

"I think it's deplorable that a proposal that obviously lacks support among the population is so casually voted through," Akesson told reporters.

Some critics had expressed concerns about biological males in women's locker rooms and prisons, and fear the simplified procedure to change legal gender will encourage confused youths to embark down the path toward surgical transitions.

Others had insisted that more study was needed given the lack of explanation for the sharp rise in gender dysphoria.

In a sign of the strong feelings it stirred, members of parliament spent six hours debating the proposal.

"There is a clear correlation with different types of psychiatric conditions or diagnoses, such as autism," Annika Strandhall, head of the women's wing of the Social Democrats (S-kvinnor), told Swedish news agency TT ahead of the vote.

"We want to pause this (age change) and wait until there is further research that can explain this increase" in gender dysphoria cases.

Kristersson, the prime minister, had defended the proposal as "balanced and responsible".

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