-Department of English-
Health Humanities Undergraduate Research
THE HISTORY OF TRANS MEDICINE:
AN OVERVIEW
Introduction
As time progresses further into the 21st century, we progress medically and socially as well. Specifically, the perspective on being transgender has changed rapidly and dramatically over the last few decades. This report is an attempt at a brief but comprehensive summary of the basic steps that led our definition, outlook, and treatment of trans people in the medical community becoming what it is today.
Historical Views on Gender Identity
Early definitions of gender and transgenderism were much more fluid than modern ones. Ancient civilizations saw women as an imperfect form of men, and believed that “mannish behavior” would cause women's genitals to unfurl from their bodies, making them a man. Gender identity as a concept was never heavily explored. People were either biologically male or female. Any deviation from this was looked at as an oddity or curiosity, and there is little documentation on their conditions.
The idea of gender being a defined binary only arose through the spread of religion, specifically Christianity, throughout the western world. Namely, scriptures like Deuteronomy 22:5 strictly prohibited cross-dressing and established rigid gender identities. The King James edition of the Bible states “The woman shall not wear that which pertaineth unto a man, neither shall a man put on a woman's garment: for all that do so are abomination unto the Lord thy God.” Because of this, deviations from traditional gendered outfits were labeled cross-dressing and were looked upon very negatively. Laws like the Masquerade Law established in New York in 1845 made dressing as the opposite sex in public outright illegal.
Public Universal Friend
Source: NPR
However, there were certain exceptions to the quickly solidifying views on gender. Public Universal Friend was a preacher from the late 1700’s who rejected their birth names and personal pronouns, and established a religious group called the Society of Universal Friends that rejected gender roles. They would, in today’s terms, be considered non-binary, and were an early case of a public figure who opposed gender norms. There were also several historical records from the 19th century that documented people who were born women that transitioned into men as they grew, who would likely be labeled intersex in today’s terms. Multiple cases like these were documented throughout the century, and could possibly be explained by several isolated incidences of 5a-Reductase 2 deficiency, in which testosterone is not broken down properly in the female body, eventually leading to full masculinization.
Although there were individual cases of flouting gender norms, the rapidly increasing influence of the Catholic church and quickly spreading religious views across the western world meant that gender roles would remain steady through the 20th century, until the work of one German physician would put the long-held gender roles into question for the first time in the medical world.
The Most Dangerous Man in Germany
Die Transvestism created the term “transvestism,” coming from the Latin words for “across” and “dressed.” He claimed that the major marker of transvestism was not homosexuality, fetishism, or delusion but rather a complex phenomenon that must be researched and studied more carefully. He also established the theory of sexual intermediates and in doing so questioned the rigid gender binary, noting that there were people with different sexual organs and physical/emotional characteristics that were stereotyped of being from the other sex. He essentially argued that all people were bisexual to a certain extent, and hypothesized that gender is limitless. Most importantly, he argued that transvestism was a “harmless inclination,” and that transvestites should be accommodated and treated with psychotherapy rather than pushed away and jailed. His humanization of trans people would contribute greatly towards how they were and still are viewed by the medical community. They ceased to be anomalies in a social sense, and became patients that could be treated and studied. Hirschfeld’s work would act as a starting point for many other researchers in the future, and would be a marker in medicine for decades.
Although Die Transvestism was infinitely important in bringing trans people to the attention of the medical community, research was still lacking in several areas. His desire to separate transvestites from homosexuals in an order to destigmatize them caused him to largely ignore those who were indeed homosexuals. He took a hegemonic approach to his subject’s interviews, choosing to interpret their words to fit his own interpretation. However, his work’s importance still cannot be denounced.
Aside from his publications, Hirschfeld also created the Institute for Sexual Science in 1919. It was the first known major medical institute for researching sexual disorders, and worked in research, sexual counseling, and education. He would also begin researching testosterone and estrogen in hormone therapy with Austrian endocrinologist Eugen Steinach. This institute would run until 1933, when it would be burned down by the Nazi party.
In 1910, German physician and sexologist Magnus Hirschfeld would publish Die Transvestism (The Transvestites), the first major publication suggesting that cross-dressers and other people who defied traditional gender roles were not perverse or morally wrong, but rather suffering from a form of gender identity crisis. To do so, he interviewed dozens of cross-dressers and trans people, listening to their experiences and documenting their stories. His work studying sexuality and gender identity would eventually cause Adolf Hitler to label him the “most dangerous man in all of Germany,” and make him a major pariah during the third Reich.
Magnus Hirschfeld
Source: Encyclopedia Britannica
Surgery and War
After the destruction of Hirschfeld’s institute, progress in trans medicine would take a short hiatus. As the world plunged into World War 2, researching sexuality and gender took a backseat to helping the war effort. Physicians hardly had time to focus on the “transvestite issue” while they were caring for injured soldiers. However, through war came an extremely important development: the first steps in gender reassignment surgery. Previous surgeries on sexual organs had existed beforehand (the first full orchiectomy, or removal of testicles, had occurred in Denmark in 1930 for a male to female transition, and the first full phalloplasty occurred on a cis male patient in 1936), but wounded soldiers with mangled genitals became the first test subjects for sexual surgeries.
In 1940, British otolaryngologist Sir Harold Gillies (who would later become to be known as the father of modern plastic surgery) would develop the first female to male gender reconstruction surgery. He would later create the earliest gender-affirming vaginoplasty in the 1950s alongside Dr. Ralph Millard Jr, which would last until a more modern technique was refined in 1974. By the 1960s, there were many centers that had begun performing gender affirming surgeries, mostly large universities like Johns Hopkins and Stanford. By 1999, around 1000 Americans had undergone gender affirming surgery.
While gender affirming surgeries became more common medically, they also grew more normalized socially. In 1953, former soldier and popular movie star Christine Jorgensen would undergo a highly publicized male to female transition. Her story was incredibly important in normalizing trans people to the general public, and her transition would inspire not just closeted trans people across the nation, but perhaps one of the most important figures in the history of trans medicine yet.
Christine Jorgensen, Source: Wired.com
Benjamin and Money: A Tale of Two Approaches
In 1966, inspired by Christine Jorgenson and his studies at Hirschfeld’s institute, German-American sexologist Harry Benjamin would publish The Transsexual Phenomenon, a medical textbook in which he argued that the dictionary definition of sex being the same as gender is untrue. He proposed that sex should instead be divided into several categories: chromosomal, genetic, anatomical, legal, gonadal, germinal, endocrine, psychological, and social. Following in Hirschfeld’s footsteps and even expanding on his ideas, he stated that the phenomenon of wanting to transition or assuming the role of a different gender was not a novel concept.
Harry Benjamin
Source: The Kinsey Institute
Although his work focused mainly on the idea of being able to pass as distinctly male or female and centered heavily on cis-normative stereotypes, Benjamin still was an incredibly important figure in trans history. His work allowed trans people to begin to be accepted by the medical community. The Transsexual Phenomenon would be cited in countless other works in the following years, and established being a “transsexual” as an official medical diagnosis. In fact, shortly after it was published, Johns Hopkins opened the Johns Hopkins Gender Identity Clinic, the first major health center for trans people. The clinic conducted major sex reassignment surgeries with the goal of aligning physical, social, and mental sex as much as possible, and conducted research on its patients. There was a very long and arduous process that candidates had to complete, and there was very little informed consent or psychological support for those who were admitted. Doctors mostly made decisions for the patients with little regard for what the patient really wanted. Similarly, the Stanford Gender Dysphoria Program was formed in 1968 with the same goal and methods. Problematic aside, these early programs were incredibly important in the research and implementation of trans medicine into modern medicine.
While Benjamin was conducting his research, another medical professional was conducting his own. In 1955, psychologist John Money proposed the idea that all infants are completely gender neutral at birth, and only by raising them by societal standards are they assigned a gender. While his idea would not gain very much traction immediately, his unorthodox methods of experimentation would soon gather the attention of the public eye.
The same year that Benjamin published The Transsexual Phenomenon, John Money encouraged the gender reassignment of David Reimer, a biologically male infant who had his penis irreversibly damaged during a botched circumcision. For years, Reimer was raised as a girl and unknowingly given hormone replacement therapy. As a child, he suffered from severe gender dysphoria and eventually developed major depressive disorder. When he was 15, he learned the truth about his sex and transitioned back to male. Reimer spoke out numerous times about his experience before ultimately committing suicide in 2004.
David Reimer
Source: Rachel Lawlor
Backlash
Once publicized, John Money’s experiment was initially viewed as a success. However, gradually, as David Reimer spoke out against his treatment, public as well as medical opinion began to turn on Money’s idea that gender was malleable. In addition, religious beliefs and anti-trans sentiment still seeped into the medical community, impacting how transgender patients were treated. Some physicians saw trans people as abominations against god and outright refused to treat them altogether . Opinions varied greatly, however, as one male-to-female transition account detailed the many different interactions they had with various doctors. The reactions to their transition from medical professionals ranged from flat out rejection, sympathy but misunderstanding, total acceptance, and everywhere in between.
In addition to basic prejudice, new developments in the medical community led to certain regressions in the recognition of trans people. One major part of this was a study by Jon Meyer, the head of Johns Hopkins’s Sexual Behaviors Consultant Unit. In his 1979 study (now long overturned), he concluded that sex-change surgery was largely unhelpful with improving the lives of trans people, and argued that by providing it, Johns Hopkins was supporting a mental illness. A few months after publishing his study, Hopkins shut down their gender identity clinic, and many other academic hospitals followed suit, citing the study as their primary motive.
Meyer’s viewpoints were far from uncommon in the medical community. In 1980, one year after his study, the American Psychiatric Association would publish the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II). It would contain “transsexualism,” defined as the desire to live as the other sex, solidifying being trans as being mentally ill.
Shifting Tides
Arguably the biggest event in the shaping of our modern medical perspective on transgender people was the HIV/AIDS crisis. In 1981, HIV/AIDS became incredibly prevalent among the LGBT+ community, and its highly publicized spread caught the eye of medical professionals and the general population alike. While the crisis brought HIV and AIDS to the public eye, it brought LGBT+ health to the medical one. It gave medical professionals a concrete metric to study, showed how queer people were disproportionately impacted by health crises, and increased medical focus on care for transgender people. More and more, medical textbooks and journals began to use the term “transgender” over “transsexual” to correct the idea that being trans was a sexual behavior rather than a internal gender one. New techniques and therapies involved in transitioning were invented as well, with puberty suppressants being used alongside hormone treatments starting from 1990 and the modern phalloplasty being developed in 1993.
Act Up Demo protesting AIDS epidemic, New York, June 1994, Source: CNN
The change from an older, more outdated medical view on trans people to the modern view for transgender people can be tracked directly through updates to the DSM. Released in 1994, the DSM IV replaced transsexualism with “gender identity disorder”, which was defined as a disturbance with which an individual strongly desires to be another sex. This definition took into account the disturbance caused within the individual due to the desire to be another gender, rather than solely focusing on the act of wanting to be another gender itself. Additionally, the World Professional Association for Transgender Health published the Standards of Care for the heath of transsexual, transgender, and gender-nonconforming people in 1980, with the most recent edition coming out in 2012. These were very important in creating baseline expectations for how trans people should be treated and increasing the access of trans people to healthcare.
Modern Views
Like all scientific research, the story of trans people in medicine is far from over. In the past decade, the way that medical professionals respond to transgender individuals has changed dramatically. In 2011, the National Institute of Health sponsored a survey to assess the impact of health science on LGBT+ populations and identify gaps in their research and opportunities to improve in those areas. In it, they stress that researchers should be very comforting and professional about the topic of LGBT health in order to make queer patients as comfortable with sharing their true stories as possible. This expectation has grown throughout the medical field. It has become a basic expectation for transgender people to be treated humanely and with respect, and while there are exceptions, medical professionals adhere to this to a reasonable degree.
The most modern publication of the DSM, DSM V, was published in 2013. Gender identity disorder was changed to gender dysphoria, shifting its focus completely from transgender individuals to the gender crisis that some face, and emphasizing that gender nonconformity is not a mental illness, but the mental dysphoria that occurs is.
Finally, in 2017, students and faculty alike at the Bloomberg School of Public Health denounced Jon Meyer’s study. Johns Hopkins responded by reopening their institute and renaming it the Center for Transgender Health. It now acts more as a place for patient care of trans people, and remains open to this day.
Johns Hopkins Center for Transgender Health, Source: Johns Hopkins
Resources
Maintaining history is crucial to forging our future. Below is a collection of databases and published articles containing information about the history of trans and intersex medicine. They serve to outline just some of the resources we have on this topic.
A collection of texts by, about, and for people that defy traditional western gender norms.
Research on the current state of trans medicine and what we can do to improve it.
A Historical Review of Gender-Affirming Medicine: Focus on Genital Reconstruction Surgery
A comprehensive review on the history of genital reconstruction surgery.
Advances in the Care of Transgender Children and Adolescents
An overview of current modern standards for caring for trans children and teenagers.
International Journal of Transgender Health
A medical journal containing various articles about a wide range of topics involving trans medicine.
An online archive dedicated to preserving trans history.