AMA Journal of Ethics^®

Gender affirmation surgery has come a long way since it was introduced 90 years ago in Europe. During its first 50 years of existence, gender affirmation surgery went from being a rarely performed procedure in Europe with variable outcomes to an accepted treatment for medical diagnoses in Europe and America. Throughout those years, there was a hard fight to bring this type of surgery out of the shadows and into the public eye as the major techniques of the field were being developed, and it was even offered as an experimental treatment option for the new diagnosis of gender identity disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980.¹

The first recorded “sex reassignment surgery,” as it was referred to at the time, took place in Berlin, Germany, at the Institute for Sexual Science in 1931.¹ During the first half of the 20th century, it was common to label gender-nonconforming individuals as pathologic and treat them exclusively for “mental imbalance” without considering the possibility of hormone or surgical therapy.² When surgery was performed, it was done for the purpose of completely reassigning a person from one sex to the other, as gender was understood in a binary context.¹

It was not until 1952 that gender affirmation surgery would become internationally recognized following the well-publicized sex reassignment surgery of World War II American veteran Christine Jorgensen, previously known as George Jorgensen Jr, in Denmark.³ Following this event, gender affirmation surgery demand spiked in Denmark, with individuals traveling from across the world to undergo the procedure.³ More than a decade after Jorgensen’s surgery, in 1966, Johns Hopkins University opened its Gender Identity Clinic and became the first US academic institution to begin performing gender affirmation surgeries.⁴ Over the course of the following decade, more than 1000 Americans underwent gender affirmation surgery at the hands of surgeons at major American university clinics.^1,3 Although the Hopkins clinic closed in 1979 due in part to public controversy surrounding a study published by the clinic’s director that apparently showed a lack of subjective improvement in patients who had undergone surgery and that was later found to be heavily biased, private practitioners rose up to fill the void.¹

The year 1979 also saw the publication of the first edition of the Standards of Care (SOC) by the Harry Benjamin International Gender Dysphoria Association, which later became known as the World Professional Association for Transgender Health (WPATH).⁵ The SOC were created to better standardize care following the closure of the Hopkins Gender Identity Clinic and to provide guidelines for when to offer surgical therapy.⁶ The addition of gender identity disorder in DSM-III, while pathologizing and stigmatizing, did increase access to the health care system for these procedures.⁵ By the mid-1980s, all of the major techniques for performing genital reconstruction had been established, with intestinal vaginoplasty being invented in 1974 and radial forearm free flap phalloplasty in 1982.⁷

As the turn of the millennium approached, policy makers set their sights on destigmatizing and depathologizing the treatment for gender incongruence, as gender affirmation surgery continued to grow and become an accepted treatment modality. The WPATH published 7 editions of the SOC between 1979 and 2012, the terminology for transgender and gender diverse identities was changed numerous times, new surgical advancements were made, and regulations were adopted to require health insurance companies to cover surgical treatments for gender incongruence.⁸ Transsexualism, as gender identity disorder was then called, was removed from the mental health disorders section of the World Health Organization’s International Classification of Diseases in 2018, and a government appeals board ruled that Medicare must cover gender affirmation surgeries in 2014.⁶ These changes happened as research studies validated the beneficial effects of gender affirmation surgery and the Endocrine Society and other national organizations published clinical practice guidelines, all of which developments contributed to the practice’s acceptance as the official standard of care.^{9,10,11,12,13,14}

We have now reached a tipping point in the field of gender affirmation surgery wherein the focus has largely shifted from fighting for its acceptance as a treatment modality and increasing patients’ access to it toward ethical stewardship of this now-validated and accessible set of procedures, although challenges remain, as access to surgical and medical care for adolescents remains politically fraught.¹⁵ This issue of AMA Journal of Ethics considers these challenges for the field and offers views of clinicians and advocates as protectors of patient autonomy and patient-centered, inclusive care.