History of Transgender Medicine

Transgender medicine did not emerge from a vacuum. It has a history spanning over a century, made up of pioneering insights, deliberate destruction, painstaking reconstruction, grave errors, and fundamental achievements. Understanding it helps explain where today’s clinical practices come from, why certain debates exist, and what lessons the past leaves us.

Berlin, 1919: The Institut fur Sexualwissenschaft

The modern history of transgender medicine begins in Berlin on July 6, 1919, when the German physician and sexologist Magnus Hirschfeld opened the Institut fur Sexualwissenschaft — the Institute for Sexual Science [1]. Hirschfeld, Jewish and openly gay, had already coined the term “Transvestiten” in his 1910 book of the same name, to describe people we would today call transgender [2]. He was convinced — at a time when very few were — that trans people acted according to their own nature, not against it, and that medicine should help them live in a way consistent with their identity.

The Institute offered medical consultations, psychological support, sex education, and — remarkably for the era — a safe refuge for trans people [1]. Hirschfeld gave them employment as domestic workers and protected them from violence and marginalization. The Institute became an international reference point, with a library of over 20,000 volumes and an unprecedented archive of clinical cases [2].

The First Surgeries

It was within the Institute that the first documented gender-affirming surgeries in the history of medicine were performed. In 1931, Dora Richter — a trans woman who had been living and working at the Institute since 1923 — was operated on by surgeon Erwin Gohrbandt [1]. After a previous orchiectomy and penectomy, Richter received a vaginoplasty, becoming the first trans person with documented clinical records to have completed a feminizing surgical pathway. Psychiatrist Felix Abraham, a collaborator at the Institute, published a scientific article on this case that same year.

Shortly after, Danish artist Lili Elbe turned to the Institute to begin her own journey. Elbe, born as Einar Wegener, underwent a series of four surgical procedures between 1930 and 1931 in Berlin and Dresden, under Hirschfeld’s initial supervision [1]. The final surgery — an attempt at uterine tissue transplantation to create a vaginal canal — ended tragically: Elbe died in September 1931 from tissue rejection. Her posthumous biography, “Man into Woman” (1933), represents one of the first public documents about gender transition and helped conceptually separate gender identity from sexual orientation.

The Nazi Destruction

On May 6, 1933, a few months after Hitler’s rise to power, a group of Nazi students raided the Institute [3]. In the following days, authorities confiscated and destroyed the entire library: over 20,000 volumes and the complete clinical archive were burned in a public bonfire on May 10, 1933, one of the symbolic acts of the Bucherverbrennungen — the Nazi book burnings [3]. The images of that bonfire, often reproduced in history books without context, depict precisely the destruction of the largest collection of knowledge about sexuality and gender identity ever assembled up to that point.

Hirschfeld, who was abroad on a lecture tour, never returned to Germany. He died in exile in Nice in 1935 [3]. Dora Richter’s fate after the ransacking of the Institute remains unknown.

The destruction of the Institute was not merely an act of cultural barbarism: it erased decades of clinical research, destroyed precious documentation, and set back the development of transgender medicine in Europe by at least a generation [1].

Christine Jorgensen and the American Turning Point (1952)

Twenty years passed before transgender medicine returned to public prominence, this time from the other side of the Atlantic. On December 1, 1952, the New York Daily News published the front-page headline: “Ex-GI Becomes Blonde Beauty.” Christine Jorgensen, a young trans woman of Danish heritage born in the Bronx, had returned from Denmark after a series of surgical procedures that included an orchiectomy (1951), a penectomy (1952), and subsequently a vaginoplasty (1954), performed at hospitals in Copenhagen [5].

Jorgensen instantly became a public figure. Unlike Hirschfeld’s patients, whose stories had remained confined to medical circles, Jorgensen had to face the morbid curiosity of the American press and public [5]. She did so with remarkable courage and a certain elegance, using her visibility to give a face and a voice to trans people at a time when the word itself did not exist in common parlance.

The Jorgensen case had a catalytic effect: it demonstrated to the medical world that surgical transition was possible and prompted a growing number of trans people to seek treatment — often clashing with an unprepared and hostile medical establishment.

Harry Benjamin and the Foundation of Modern Trans Medicine

If Hirschfeld was the visionary and Jorgensen the public face, Harry Benjamin was the clinical architect of modern transgender medicine [4]. A German-American endocrinologist, Benjamin had met Hirschfeld in Berlin and absorbed his empathetic and scientific approach. During the 1940s and 1950s, he worked privately with trans patients in New York, developing hormone therapy protocols at a time when most of his colleagues refused even to acknowledge the existence of the issue.

In 1966, at age 81, Benjamin published “The Transsexual Phenomenon,” the first comprehensive medical text on transsexuality [4]. The book was revolutionary for several reasons: it treated the trans condition not as a psychological disorder to be cured with psychotherapy, but as a condition with somatic foundations that required medical treatment. Benjamin proposed a classification scale (the “Sex Orientation Scale”) and clearly advocated that medical transition — hormonal and surgical — was the appropriate treatment.

The impact was enormous. In the decade following publication, the institutional landscape changed radically: from a situation in which, in 1965, practically no institutional support existed, by 1975 there were approximately twenty university medical centers offering treatments, with about a thousand people having received surgical interventions [4]. The organization founded in his honor, the Harry Benjamin International Gender Dysphoria Association, would become WPATH (World Professional Association for Transgender Health) in 2007 [9].

John Money: Contributions and Controversies

Parallel to Benjamin’s work, psychologist and sexologist John Money introduced the concept of “gender role” in 1955 and subsequently “gender identity,” contributing to the theoretical separation of biological sex from gender identity [6]. This conceptual contribution was important for the development of transgender medicine.

However, Money is today remembered also — and perhaps primarily — for the tragic case of David Reimer [6]. In 1966, Reimer, an infant whose penis had been severely damaged during a circumcision, was surgically reassigned as female on Money’s recommendation, who maintained that gender identity was entirely a product of upbringing. Money presented the case as a success for years, but the reality was different: Reimer never identified as female, suffered enormously during childhood and adolescence, and reassumed a male identity at age fifteen. The story was made public in 1997 by sexologist Milton Diamond, who described it as a refutation of the theory of total gender plasticity [6]. David Reimer took his own life in 2004.

The Reimer case, while not directly involving a transgender person, had important consequences for transgender medicine: on one hand, it helped strengthen the idea that gender identity has deep biological foundations and is not simply moldable through upbringing; on the other, it highlighted the ethical risks of medical approaches that do not respect the autonomy and subjective experience of the individual.

The Evolution of Diagnostic Categories

The history of transgender medicine is also the history of how the medical community has classified — and often pathologized — the trans experience [7]. This evolution reflects a slow but steady shift from pathologization toward recognition.

Transsexualism (1978-1990): The diagnosis of “transsexualism” first appeared in the ICD-9 in 1978, classified under “sexual deviations and disorders” [7]. The DSM-III, in 1980, introduced an analogous diagnosis. The language itself — “deviation” — reveals the mindset of the era.

Gender Identity Disorder (1990-2013): With the DSM-IV (1994) and ICD-10 (1990), the diagnosis was reformulated as “Gender Identity Disorder” [7]. Although the term was less overtly stigmatizing, it still classified trans identity as a mental disorder, with all the implications that entailed in terms of social perception and access to care.

Gender Dysphoria (2013): The DSM-5, published in 2013, introduced the term “gender dysphoria,” moving it from the category of sexual disorders to its own category [7]. The change was significant: the diagnosis focused on the distress (dysphoria) resulting from the incongruence between identity and body, not on the identity itself. Being trans was no longer a disorder; the suffering associated with it could be, if present.

Gender Incongruence (2019-2022): The most radical change came with the ICD-11, approved by the World Health Organization in 2019 and entering into force in 2022 [8][13]. Gender incongruence was moved out of the chapter on mental disorders and placed in a new chapter dedicated to “conditions related to sexual health.” Unlike the DSM-5, the ICD-11 does not require the presence of distress or dysfunction for the diagnosis. The trans condition, for the first time in an international classification, is no longer considered a mental illness [8].

The WPATH Standards of Care: From Gatekeeping to Autonomy

The evolution of the WPATH Standards of Care represents a microcosm of the transformation of transgender medicine as a whole [9].

The first version was published in 1979, when the organization was still called the Harry Benjamin International Gender Dysphoria Association. The initial versions (1-4, from 1979 to 1990) followed a rigidly gatekeeping model: the physician decided whether the person was “trans enough” to access care [9]. The criteria were restrictive and required separate evaluations by multiple mental health professionals, mandatory psychotherapy, and a “real life experience” — a period during which the person had to live in the affirmed gender without medical support, often exposing themselves to discrimination and violence.

The fifth version (1998) introduced an initial softening, recommending but not requiring psychotherapy [9]. The sixth (2001) offered greater flexibility and individualization of care, while maintaining the general framework.

The seventh version (2012) marked a paradigm shift: WPATH adopted an approach more oriented toward patient rights, recognized the variability of gender identities, and further relaxed the requirements [9]. However, it remained a model based on diagnosis and professional evaluation as prerequisites for access to care.

Version 8, published in 2022, represents the most significant update [10]. It is the first version developed with an evidence-based methodology. It includes for the first time a separate chapter for the care of adolescents, explicitly recognizes non-binary identities, and adopts depathologizing language, speaking of “transgender and gender diverse people” rather than patients with a disorder [10]. The emphasis shifts from diagnosis to information, from control to accompaniment.

The Informed Consent Model

In parallel with the evolution of the Standards of Care, the informed consent model has been developing since the early 2000s, representing an alternative to the traditional gatekeeping model [11]. Formalized at the Callen-Lorde Community Health Center in New York, this model eliminates the mandatory psychiatric evaluation as a prerequisite for accessing hormone therapy.

In the informed consent model, the physician informs the person about the risks, benefits, and limitations of hormone therapy, and the decision is made jointly, respecting the patient’s autonomy [11]. Neither a psychiatric diagnosis nor a letter from a therapist is required. The approach is based on a simple principle: trans people are capable of making informed decisions about their own bodies, like any other adult patient.

The clinical outcomes have been positive: clinics that adopted the informed consent model — starting from 2007 — have registered a significant increase in the number of people in care without a corresponding increase in negative outcomes [11]. The model is now widespread primarily in the United States, Canada, Australia, and parts of the United Kingdom, while in many European countries a model based on preliminary psychological or psychiatric evaluation still prevails.

What This History Teaches Us

A century of transgender medicine leaves us with some clear lessons. The first: trans people have always existed, and medicine recognized them much earlier than common knowledge suggests — only to forget them when ideological destruction erased the evidence [1]. The second: progress has not been linear. Every achievement was preceded by resistance, and sometimes followed by steps backward. The third: errors — from the Reimer case to forced pathologization, from paternalistic gatekeeping to bureaucratic barriers — have had real consequences on people’s lives [6]. The fourth: the direction of change, over the long term, is clear and consistent. From “sexual deviation” to gender incongruence, from medical control to informed consent, from silence to visibility: the trajectory points toward the recognition of the autonomy and dignity of trans people [7][8].

This history is not finished. Today’s challenges — access to care for minors, reduction of waiting lists, adoption of informed consent, training of healthcare professionals — are the chapter we are writing now. Knowing the past helps us write it better.