Several themes in the history of clinical treatment of transgender-related behavior from the 19th century until today are listed below:

• De-emphasis on a mental health-based understanding of gender dysphoria, together with an increased emphasis on a medical understanding of this condition. 

• Rising politicization of treatments for gender dysphoria (e.g., surgeries, hormone therapy, puberty blockers)

• Changing availability of treatments over time (e.g., decisions by certain healthcare providers to cease treatment provision, states implementing treatment bans).  For example, in some conservative states, these treatment bans were initially based on the view that it was necessary to protect children from receiving treatment that they might later regret, but subsequently, treatment bans in certain states were extended to adults.

• Varying terminology used over time and changes in the terms' definitions (e.g., transvestite, transgenderism, transsexual, transgender, gender identity disorder, gender dysphoria)

• Ongoing concerns about the bioethics of treatment provision for this condition

• Conflicting views of the treatments from a patient rights' perspective versus a patient safety perspective.  This issue comes up especially when balancing a minor patient's desire to immediately pursue treatment with a slower approach emphasizing precision in diagnosis in order to avoid possible instances of regret after treatment (although there are relatively few reports of these cases) due to certain irreversible changes (e.g., surgeries, changes brought about by hormone therapy).

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Clinical History Timeline

The section below provides a timeline of important events in treatment history:

• People who say that they are uncomfortable with their biological sex and the roles associated with their gender have been reported in the medical literature since the middle of the 19th century (Koh, 2012). 

• Some of the first sex reassignment surgeries were developed for people who were diagnosed with hermaphroditism more than a century ago.  Johns Hopkins University opens the Brady Urological Institute in 1915 that developed a surgical protocol for creating binary sex from someone who was diagnosed with “hermaphroditism” (Gill-Peterson, 2018).  Today this older term is referred to as “intersex.”  According to the National Library of Medicine’s Medline Plus, “intersex is a group of conditions where there is a discrepancy between the external genitals and the internal genitals (the testes and ovaries).”  These conditions can be related to either chromosomes or gonads.  This condition is different than gender dysphoria as we understand it today but as Gill-Peterson points out, the history of the medical treatment of intersex people is important because subsequently transgender people began to see some of the same doctors who treated intersex people.  The surgical protocol was developed by Hugh Hampton Young, a surgeon who directed the Institute.  Medical sex reassignment surgeries are performed on infants, children, and teenagers. 

• Alan Hart transitions to become a trans man with medical assistance from the University of Oregon in 1917-18 (Gill-Peterson, 2018).

• Harry Benjamin, an endocrinologist and sexologist, starts treating his first “transvestite” patient in the late 1920s (Gill-Peterson, 2018).  At that time, “transvestite” is defined as someone who has a desire to dress in the clothes of the opposite sex.  The terms used to describe these behaviors overlapped with such terms as "homosexuality" and "inversion."

• The development of synthetic hormones that affect certain biological sex-related characteristics of the human body and their medical use in humans occurred nearly 80 years ago.  At the Brady Urological Institute, hormone therapy began to be integrated into the medical treatment of individuals diagnosed with hermaphroditism as new synthetic hormones were developed in the 1930s such as stilbestrol (discovered in 1938 and approved for medical use the following year) and lutecylol (Gill-Peterson, 2018).

• Transgender adults, youth, and children (who were not diagnosed with hermaphroditism) approached physicians for medical treatment of their condition as early as the late 1930s.  As the news traveled that an individual with hermaphroditism could have his/her sex changed with surgery and/or medication, in 1938 some people whom we might now define as transgender approached the Brady Urological Institute for medical treatment of their condition (Gill-Peterson, 2018). 

• The first edition (1952) of the Diagnostic and Statistical Manual of Mental Disorders (DSM) included the disorder, transvestism, in a sub-group of sexual deviations, but no disorder was included that is similar to gender identity disorder or dysphoria.  Up until this time, the diagnoses homosexuality, fetishism, gender identity disorder, and related conditions were regarded as types of sexual perversion that were considered ethically objectionable (Koh, 2012).

• The terms used to describe some of the characteristics of the condition that we refer to as "gender dysphoria" today and the way we think about gender role and identity are refined in the 1950s.  

  • Harry Benjamin distinguishes “transvestism” from “transsexualism” in the article “Transsexualism and Transvestism as Psychosomatic and Somatopsychic Syndromes” in the American Journal of Psychotherapy in 1954.  In this article he defined transexualism as a condition in someone who has  “…the intense and often obsessive desire to change the entire sexual status including anatomical structure.  While the male transvestite, enacts the role of a woman, the transsexualist wants to be one and function as one, wishing to assume as many of her characteristics as possible, physical, mental, and sexual.”

  • In 1955 John Oliven, a psychiatrist, proposes the term “transgenderism” to replace “transsexualism” in his book, Sexual Hygiene and Pathology: A Manual for the Physician.

  • In 1957, John Money, a psychologist, argued that gender is a social construct and advocated for the concept of gender role and identity as distinguished from sex role (Koh, 2012).  

• The first gender identity clinic in the United States opened at Johns Hopkins University in Baltimore, MD in 1966.  This clinic was founded by John Money.  

• Also in 1966 Harry Benjamin publishes the seminal book, The Transsexual Phenomenon, in which he argues that transsexuals were a group of people that were distinct from transvestites.  He challenged the psychotherapeutic treatment paradigm for transsexual individuals, arguing that it didn’t lessen their behavior or desires and instead advocated hormone therapy and gender affirmation surgery.  

• Eight other university-based gender identity clinics open in the United States from the mid 1960s until the 1970s, including one at Baptist Medical Center in Oklahoma City, OK.  These clinics mark the first wave of clinics providing gender identity services in the country.

• The Harry Benjamin International Gender Dysphoria Association (HBIGDA) is formed in 1978.  This association developed the first version of the Standards of Care for Gender Identity Disorders (SOC) in 1979. (Note: HBIGDA is later renamed the World Professional Association for Transgender Health (WPATH) in 2006.

• By the early 1970s, two of the clinics in the first wave, at the University of Washington and the University of Minnesota, stopped providing gender identity services to patients.

• In 1977, the Baptist General Convention of Oklahoma was made aware that some physicians at the Baptist Medical Center in Oklahoma City provided gender affirming surgery.  Certain surgeons who provided this treatment strongly argued that they should be permitted to continue it.  They issued a joint statement that said, “[I]f Jesus Christ were alive today, undoubtedly he would render help and comfort to the transsexual." Despite their efforts, the board of directors voted overwhelmingly to prohibit such surgeries in the future.

• Johns Hopkins University announced in 1979 that it will cease to offer sex reassignment surgeries and will close its gender identity clinic following a study by Jon Meyer that concluded that while such surgeries were “subjectively satisfying” to the individuals who received them, the operations gave “no objective advantage in social rehabilitation.”

• In 1980, the third edition of the DSM (III) includes the diagnoses gender identity disorder and transsexualism for the first time.

• The diagnosis, gender identity disorder, is used in the DSM until 2013 when the name is changed to gender dysphoria at the time the fifth edition is published (DSM-V).  This change reflected a compromise with advocates, some from the field of social work, who called for the disorder to be completely removed from the fifth edition.

• Medicare announced in 2014 that it had decided to end a blanket denial of coverage on gender transition-related surgery.

• The federal government issued regulations in 2016 which applied non-discrimination principles that included gender identity to health insurance coverage as part of the Affordable Care Act- Section 1557. This section prohibits discrimination in health programs and activities receiving federal assistance 

• In 2016, media reports suggest that gender affirmation surgeries are becoming more widely available at US hospitals. The rise in the number of hospitals that offer gender affirming surgeries represents the second wave of clinics to open following the closure of the clinics in the first wave in the 1970s.

• In 2017, Johns Hopkins University announced that it will restart gender transition-related surgeries.

• The World Health Organization (WHO) announced in 2019 that it would reclassify gender identity disorder as gender incongruence, remove it from the mental disorders chapter in the latest revision of the International Classification of Diseases (ICD-11), and instead place it in the sexual health chapter.

• In June 2020, the federal government eliminated the prohibition on discrimination based on gender identity and specific health insurance coverage protections for transgender people.  However just 3 days later after this event in June 2020, the US Supreme Court ruled that sex discrimination included sexual orientation and gender identity in the employment setting.  Subsequently in August 2020 a federal judge blocked the removal of the non-discrimination protections in the provision of health care for transgender people.

  • The president signed an executive order in January 2021 on Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation that provided protections to transgender people in healthcare.

  • A few months later in May 2021, the administration took action that prevents "...discrimination by any health program or activity that receives HHS financial assistance, such as subsidies, grants or certain insurance contracts" according to this Washington Post article.  This action applies to Title IX of the civil rights law.

• In January 2021, a number of state legislatures began considering bills that would prevent physicians from treating transgender youths with puberty-blockers, hormone therapy, and sex reassignment surgery, including South Dakota, South Carolina, Colorado, Florida, Oklahoma, Missouri, Kentucky, Georgia, and Texas.  A current full list of these states is available here.

  • ​The state of Arkansas was the first to pass such a bill in March 2021.​  As of February 2023, five states (i.e., Alabama, Arizona, Arkansas, Tennessee, Utah) have passed legislation that restricts gender affirming care for youth such as puberty blockers, hormonal treatments, and sex reassignment surgeries.  Two states, Florida and Texas, have attempted to restrict treatments by executive order.  The state of Alabama has one of the more restrictive policies, making it a felony for health providers to prescribe puberty blockers, hormones or perform gender affirming surgeries.

  • By April 2023, thirteen states have restricted gender-affirming medical care for young people under the age of 18, with bans under review in another two states.

• The Department of Veterans Affairs announced in June 2021 that it would offer gender confirmation surgery to transgender veterans as part of its health care coverage.  This announcement reversed a ban on these surgeries that was implemented in 2013. ​

• Although previous bills that restricted transition-related care focused on youth, in February 2023 five states introduced legislation that would restrict gender affirming care for adults.  If passed, some bills would prohibit the provision of gender affirming care up to age 21 while others would prohibit this care for all ages.  Other bills would prevent the state's Medicaid program from working with insurers that cover gender affirming care.

  • In April 2023, Missouri became the first state to restrict gender-affirming medical care for people of all ages.  Under Missouri's emergency rule, clinicians are prohibited from providing gender-affirming care unless they comply with a number of restrictions, including the provision of 18 months of psychiatric assessment.  According to the rule, any mental health issues must be resolved prior to the receipt of gender affirming care. 

  • Seven states, as of April 2023, ban their Medicaid programs from providing some kind of gender-affirming care to people of all ages. 

  • Meanwhile, other states such as Maryland required the state Medicaid program to expand coverage for gender affirming treatment.

• By June 2023, 17 states had implemented bans or significant new restrictions on some or all gender-affirming care for minors, and most ended the use of hormone treatments and puberty blockers.  Also during June, a federal judge struck down an Arkansas law that prevented doctors from administering hormone treatments or puberty blockers to transgender youth, and also barred gender transition surgeries.  This case has been widely watched since it is the first decision on an issue that legal experts believe will take years to move through the courts, possibly going to the Supreme Court.

• The U.S. Conference of Catholic Bishops voted in June 2023 to create a body of their members who would draft a proposal of their first bioethics directives for Catholic health care institutions that treat transgender people.

• The American Academy of Pediatrics reconfirmed their support for gender-related treatments for youth in August 2023, but also commissioned a systematic review of medical research on the treatments, following similar efforts in Europe that found uncertain evidence for their effectiveness in adolescents.  Some European health ministries see this issue from the perspective of balancing patient rights with patient safety and precision.

• A group of transgender youth and their families in Tennessee asked the U.S Supreme Court in November 2023 to block their state's ban on gender-related care​.  This request makes the first time the U.S. Supreme Court has been petitioned to address a number of recent bans passed by state legislatures that target this kind of healthcare. 

• The National Health Service (NHS) in England decided to restrict gender treatment for youth in April 2024, making it the fifth European country to do so since 2020.  The NHS limited gender-related medications following a  four year long review that concluded there was a lack of evidence of benefit and concern for long term possible harm.

 

*The citations on this page come from the research literature and other publications and are available upon 

request.