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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.

Figure 1-1

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

The 1940s saw the emergence of pioneering influences in America, particularly Alfred Kinsey, the biologist who founded the Institute for Sex Research at Indiana University in 1947 (now known as the Kinsey Institute).5 Kinsey was one of the first to use the term “transsexual” in his gender studies, and he helped introduce America to this term that was to reflect a concept of an “intermediate sex.”6 To this day, the Kinsey Institute ...

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