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.
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.