Gender-affirming care has a long history in the U.S. and not just for transgender people
Sign at Kentucky Capitol on March 29 during a protest of anti-transgender legislation now being challenged in federal court. (Kentucky Lantern photo by McKenna Horsley)
In 1976, a woman from Roanoke, Virginia, named Rhoda received a prescription for two drugs: estrogen and progestin. Twelve months later, a local reporter noted Rhoda’s surprisingly soft skin and visible breasts. He wrote that the drugs had made her “so completely female.”
Indeed, that was the point. The University of Virginia Medical Center in nearby Charlottesville had a clinic specifically for women like Rhoda. In fact, doctors there had been prescribing hormones and performing surgeries – what today we would call gender-affirming care – for years.
The founder of that clinic, Dr. Milton Edgerton, had cut his teeth caring for transgender people at Johns Hopkins University in the 1960s. There, he was part of a team that established the nation’s first university-based Gender Identity Clinic in 1966.
When politicians today refer to gender-affirming care as new, “untested” or “experimental,” they ignore the long history of transgender medicine in the United States.
It’s been nearly 60 years since the first transgender medical clinic opened in the U.S., and 47 years since Rhoda started her hormone therapy. Understanding the history of these treatments in the U.S. can be a helpful guide for citizens and legislators in a year when a record number of bills in statehouses target the rights of transgender people.
Treating gender in every population
As a trans woman and a scholar of transgender history, I have spent much of the past decade studying these issues. I also take several pills each morning to maintain the proper hormonal balance in my body: spironolactone to suppress testosterone and estradiol to increase estrogen.
When I began HRT, or hormone replacement therapy, like many Americans I wasn’t aware that this treatment had been around for generations. What I was even more surprised to learn was that HRT is often prescribed to cisgender women – women who were assigned female at birth and raised their whole lives as women. In fact, many providers in my region already had a long record of prescribing hormones to cis women, primarily women experiencing menopause.
I also learned that gender-affirming hormone therapies have been prescribed to cisgender youths for generations – despite what contemporary politicians may think. Disability scholar Eli Clare has written of the history and continued practice of prescribing hormones to boys who are too short and girls who are too tall for what is considered a “normal” range for their gender. Because of binary gender norms that celebrate height in men and smallness in women, doctors, parents and ethicists have approved the use of hormonal therapies to make children conform to these gender stereotypes since at least the 1940s.
Clare describes a severely disabled young woman whose parents – with the approval of doctors and ethicists from their local children’s hospital – administered puberty blockers so that she would never grow into an adult. They deemed her mentally incapable of becoming a “real” woman.
The history of these treatments demonstrates that hormone therapies and puberty blockers have been used on cisgender children in this country – for better or for worse – with the goal of regulating the passage from girlhood to womanhood and from boyhood to manhood. Gender stereotypes concerning the presence or absence of secondary sex characteristics – too tall, too short, too much body hair – have all led parents and doctors to perform gender-affirming care on cisgender children.
For over half a century, legal and medical authorities in the U.S. have also approved and administered surgeries and hormone therapies to force the bodies of intersex children to conform to binary gender stereotypes. I myself had genital surgery in infancy to bring my anatomy into alignment with expectations for what a “male” body should look like. In most cases, intersex surgeries are unnecessary for the health or well-being of a child.
Historians such as Jules Gill-Peterson have shown that early advances in transgender medicine in this country are deeply interwoven with the nonconsensual treatment of intersex children. Doctors at Johns Hopkins and the University of Virginia practiced reconstructing the genitalia of intersex people before applying those same treatments on transgender patients.
Given these intertwined histories, I contend that the current political focus on prohibiting gender-affirming care for transgender people is evidence that opposition to these treatments is not about the safety of any specific medications or procedures, but rather their use specifically by transgender people.
How transgender people access care
Many transgender people in the U.S. have deeply complicated feelings about gender-affirming care. This complexity is a result of over half a century of transgender medicine and patient experiences in the U.S.
In Rhoda’s time, medical gatekeeping meant that she had to live “full time” as a woman and prove her suitability for gender-affirming care to a team of primarily white, cis male doctors before they would give her treatment. She had to mimic language about being “born in the wrong body” – language invented by cis doctors studying trans people, not by trans people themselves. She had to affirm she would be heterosexual and seek marriage and monogamy with a man. She could not be a lesbian or bisexual or promiscuous.
Many trans people still need to jump through similar hoops today to receive gender-affirming care. For example, a diagnosis of “gender dysphoria,” a designated mental disorder, is sometimes required before treatment. Many trans people argue that these preconditions for access to care should be removed because being trans is an identity and a lived experience, not a disorder.
Feminist activists in the 1970s also critiqued the role of medical authority in gender-affirming care. Writer Janice Raymond decried “the transsexual empire,” her term for the physicians, psychologists and other professionals who practice transgender medicine. Raymond argued that cis male doctors were making an army of trans women to satisfy the male gaze: promoting iterations of womanhood that reinforced sexist gender stereotypes, ultimately ushering in the displacement and eradication of the world’s “biological” women. The origins of today’s gender-critical, or trans-exclusionary radical feminist, movement are visible in Raymond’s words. But as trans scholar Sandy Stone wrote in her famous reply to Raymond, it’s not that trans women are unwilling dupes of cis male medical authority, but rather that we have to strategically perform our womanhood in certain ways to access the care and treatments we need.
The future of gender-affirming care
In many states, especially in the South, where I live, governors and legislatures are introducing bills to ban gender-affirming care – even for adults – in ignorance of history. The consequences of hurried legislation extend beyond trans people, because access to hormones and surgeries is a basic medical service many people may need to feel better in their body.
Prohibitions on hormone therapy and gender-related surgeries for minors could mean ending the same treatment options for cisgender children. The legal implications for intersex children may directly clash with proposed legislation in several states that aims to codify “male” and “female” as discrete biological sexes with certain anatomical features.
Prohibitions on hormone replacement therapy for adults could affect access to the same treatments for menopausal women or limit access to hormonal birth control. Prohibitions of gender-affirming surgeries could affect anyone’s ability to access a hysterectomy or a mastectomy. So-called cosmetic surgeries such as breast implants or reductions, and even facial feminization procedures such as lip fillers or Botox, could also come under question.
These are all different types of gender-affirming procedures. Are most Americans willing to live with this level of government intrusion into their bodily autonomy?
Almost every major medical organization in the U.S. has come out against new government restrictions on gender-affirming care because, as doctors and professionals, they know that these treatments are time-tested and safe. These treatments have histories reaching back over 50 years.
Trans and intersex people are important voices in this debate, because our bodies are the ones politicians opposing gender-affirming care most frequently treat as objects of ridicule and disgust. Legislators are developing policies about us despite the fact that most Americans say they do not even know a trans person.
But trans and intersex people know what it is like to have to fight to access the care and treatment we need. And we know the joy of finally feeling comfortable in our own skin and being able to affirm our gender on our own terms.
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G. Samantha Rosenthal