The term gender dysphoria describes a heterogeneous group of individuals who express varying degrees of discomfort with or disassociation from their anatomic gender. Some people with this condition, in order to manage the discrepancy or imbalance they experience, desire to possess the secondary sexual characteristics of the opposite sex. Not all transgender persons have gender dysphoria. For those who do, medical and surgical therapy can play a pivotal role in relieving their psychological discomfort.
Over the past several decades, there has been significant progress in the understanding and treatment of individuals suffering from gender dysphoria. In 1984, Dr Milton Edgerton noted that, “transsexualism is a severe, and pathologic condition that is undesirable for both the patient and society…and non-surgical treatment continues to be expensive, time-consuming, and enormously disappointing.” Much has changed since Edgerton’s statement. Advances in the psychological, medical, and surgical care of individuals with gender dysphoria have resulted in a multidisciplinary approach, aimed at improved quality of life and destigmatization for this underserved and diverse population. In addition, social and political changes have raised awareness as to the importance of providing safe and affirming environments, free from discrimination. In 2010, The World Professional Association for Transgender Health (WPATH) released a statement calling for the de-psycho-pathologization of gender nonconformity, stating that, “the expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally diverse human phenomenon [that] should not be judged as inherently pathologic or negative.”
WPATH developed the Standards of Care (SOC) to help provide “the highest standards” of care for transgender individuals. The SOC state that the overarching treatment goal is “…lasting personal comfort with the gendered self, in order to maximize overall health, psychological well-being and self-fulfillment.” Since WPATH published the first version of the SOC in 1979, the guidelines have been updated 6 times, reflecting increasing understanding of the transgender population and the delivery of optimal care.
Pyschosexual development and differentiation entails 3 major components:
Gender identity, referring to one’s sense of belonging to the male or female sex category, a combination of both, or neither, regardless of the sex assigned at birth;
Gender role, sexually dimorphic behaviors and psychological characteristics within the population, such as toy preferences, clothing, and mannerisms; and
Sexual orientation, one’s pattern of erotic responsiveness as reflected in the sex of one’s partner(s).
As noted by the Institute of Medicine’s 2011 report on the health of lesbian, gay, bisexual, and transgender people, transgender individuals represent a diverse group of people who are defined according to their gender identity and presentation. This group includes persons whose gender identity differs from the sex originally assigned to them at birth or whose gender expression varies significantly from what is traditionally associated for that sex (ie, people identified as male at birth who are perceived as feminine and subsequently identify as female, and people identified as female at birth who appear more masculine and later identify as male). In addition, transgender persons may vary from or reject traditional cultural conceptualizations of gender in terms of the male-female dichotomy, or “binary.” The Institute of Medicine’s study also reported that the transgender population is varied in sexual expression and sexual orientation. Transgender people can be heterosexual, homosexual, or bisexual in their sexual orientation. Some lesbians, gay men, and bisexuals are transgender; most are not.
Some transgender individuals have undergone medical interventions to alter their sexual anatomy and physiology; others wish to have such procedures in the future, and still others do not request medical or surgical intervention. In recent years, recognition that some individuals do not see themselves in the traditional male or female gender role has gained acceptance. Gender nonconforming or gender expansive describes a difference between an individual’s gender identity, role, or expression and that of cultural norms. Some, but not all, gender-nonconforming individuals experience gender dysphoria.
Although early estimates on the prevalence of gender dysphoria were focused on identification of individuals for gender confirmation surgery, it was later realized that some individuals neither desired, nor were candidates for, such surgery. Early estimates of the prevalence of transsexualism were 1 in 37,000 biological males and 1 in 107,000 biological females. Interestingly, approximately 3 times as many biological males as compared with biological females sought genital surgery. This historical discrepancy may exist for multiple reasons, including less accessibility, and more complicated—and expensive—surgical options available for biological females. However, with increased third-party coverage for gender confirmation surgery, there has been a corresponding increase in the number of biological females seeking genital surgery. More recent data estimate that 1 in 11,900 adult biological males and 1 in 30,400 adult biological females undergo genital procedures.
The true prevalence of gender dysphoria is likely much greater than these early estimates. With increased advocacy, acceptance, and access to care, individuals are now able to seek medical attention in an atmosphere free from harassment or shame.
Transsexualism, gender dysphoria, and gender variance have been recorded throughout history and across cultures. These feelings have manifested as a spectrum of findings ranging from a conflict or feelings of inappropriateness of the assigned sex to a desire to surgically change one’s external appearance. References to these conditions are included in, for example, the ancient Greek literature of Herodotus, the lives of the Roman emperors Caligula and Elagabalus, the literature of Shakespeare, and accounts of the French diplomat Chevalier d’Eon.
In addition, the surgical alteration of one’s genitalia has occurred for millennia. Eunuchs, or castrated men, have existed since Biblical times, and self-inflicted operations were described in seventeenth century diaries as providing, “great and lasting subjective relief of gender dysphoria.” Moreover, in South Asia, the Hijra, or “third sex,” are boys who undergo voluntary demasculinization surgery, often consisting of removal of the penis, testes, and scrotum. This surgery prevents the development of secondary sexual characteristics and maintains a childlike appearance. Likewise, in Thailand, the Kathoey, sometimes referred to as ladyboys, may range from men who dress as women to what may more commonly be referred to as transgender.
In the modern medical sense, accounts of transsexualism were first mentioned in the German medical literature by Friedrich in 1830, followed by a description of a case of “transvestism” by Westphal in 1870. However, it is Magnus Hirschfeld, a German physician and pioneer in the field of sexology, who is credited with the term “transsexualism,” when he used the term seelischer transsexualismus or “psychic transsexualism” in 1923. Hirschfeld founded the Institut fuer Sexualwissenschaft (Institute for Sexual Science) in Berlin in 1919 and was credited for referring the first male-to-female patient for surgery. In addition, Hirschfeld oversaw the initial surgical management of the Danish transgender woman, Lili Elbe, who traveled to Berlin for removal of her testicles in 1931. Elbe eventually succumbed following 5 surgical procedures, including failed ovarian and uterus transplants by the surgeon Kurt Warnekros at the Dresden Municipal Women’s Clinic. It is Dr Felix Abraham, a German surgeon, who was the first to report and publish his experience with staged vaginoplasty on 2 patients, in 1931. Abraham described the surgery as “…a kind of emergency surgery necessary to save patients from worse self-inflicted procedures.” The first documented female-to-male phalloplasty procedure was performed by renowned British surgeon Sir Harold Gillies in 1945.
In 1949, David O. Cauldwell, an American physician, used the term “psychopathia transexualis” in describing an individual who desired to be a member of the opposite sex. This was significant in delineating the difference between “transsexualism” and “transvestism.” In this sense, transvestism was used to describe dressing or acting in a style typically associated with the “opposite sex.” The contemporary study of transsexualism is credited to a public lecture and paper by Dr Harry Benjamin in 1953. Benjamin (1885–1986), a German-born physician, who had met Magnus Hirschfeld while in Berlin, received his doctorate for a dissertation regarding tuberculosis. Dr Benjamin also had an interest in hormonal research and sexual medicine. Following a professional visit to the United States in 1913, Dr Benjamin’s return to Germany was disrupted when the ship on which he was traveling was caught mid-Atlantic by the Royal Navy during the outbreak of World War I. Preferring to return to the United States rather than be treated as an enemy alien in a British internment camp, Dr Benjamin began practicing general medicine in New York in 1915. With his interest in sexual medicine, Dr Benjamin began treating transgender individuals. He believed in a physiologic basis of transsexualism, drawing the distinction between transsexualism and transvestism. The medical, legal, political, and social climate at this time was generally unaccepting of persons of nontraditional gender identity and sexual orientation. For example, wearing clothing of the opposite sex in public, male castration, and homosexuality were illegal. Medical treatments for such “disorders” often consisted of electroconvulsive therapy, lobotomy, and forced drugging. In 1966, Benjamin’s book, The Transsexual Phenomenon , raised awareness of the potential benefits of sex reassignment surgery, and, in 1979, The Harry Benjamin International Gender Dysphoria Association (now known as WPATH) was formed to further research in the subject and knowledge exchange among physicians and other physical and mental health care providers.
The case of Christine Jorgensen, an American who underwent surgery in Denmark in the 1950s, drew international attention to the field of transsexualism. The case was published in the Journal of the American Medical Association in 1953, and the Danish physician Dr Christian Hamburger detailed the hormonal and surgical therapy provided to Ms Jorgensen. Following permission by the Danish Ministry of Justice, Ms Jorgensen underwent surgical castration and penile amputation. The following year, Ms Jorgensen requested removal of the “last visible remains of the detested masculinity” and underwent additional surgery to feminize her genitalia. However, per the requests of the patient, no vaginoplasty was performed. Dr Hamburger concluded by stating that, “the goal was attained; by hormonal feminization and operative demasculinization the patient’s soma harmonized with the pronounced feminine psyche.”
Other notable individuals include Dr Renée Richards, an American ophthalmologist and professional tennis player who underwent sex reassignment surgery in 1975. Following denial of entry into the 1976 US Open by the United States Tennis Association, she disputed the ban. In 1977, the New York Supreme Court ruled in her favor.
In the 1950s, Dr Georges Burou, a French gynecologist practicing in Casablanca at the Clinique du Parc, described the anteriorly pedicled penile skin flap inversion technique. Dr Borou is reported to have performed more than 3000 male-to-female sex reassignment procedures, some on famous female impersonators.
In America, Dr Milton Edgerton is credited with establishing the first multidisciplinary center for care of the transgender patient. The Johns Hopkins University Gender Identity Clinic was formed in 1965 and was composed of representatives from psychiatry, psychology, plastic surgery, gynecology, urology, and endocrinology. This multidisciplinary clinic was important in establishing a method of preoperative evaluation and postoperative care. This clinic allowed the health care team to evaluate lessons learned from the operative experience. In 1979, Dr Jon Meyer, a psychiatrist at Johns Hopkins University, and his colleagues published a follow-up study of 100 patients treated at the Hopkins Gender Identity Clinic. Of these patients, 34 underwent surgery and 66 did not. In this study, the investigators described 2 groups of patients: those individuals who will self-select for or against surgery. Interestingly, Meyer noted that in both groups, improvement was demonstrated over time. Furthermore, the study found that although sex reassignment surgery “confers no objective advantage in terms of social rehabilitation…it remains subjectively satisfying to those who have…undergone it.” This finding is consistent with the idea that not all individuals with gender dysphoria request surgery.
In 1969, additional centers were formed in the United States. These centers included the Stanford Medical Center under the guidance of Drs Norman Fisk and Donald Laub; Trinidad, Colorado under the leadership of Dr Stanley Biber; and Neenah, Wisconsin under the direction of Dr Eugene Schrang. In Europe, centers opened at the University Hospital of the Free University of Amsterdam under the leadership of Drs Louis Gooren, F.G. Bouman, Peggy Cohen-Kettenis, and J. Joris Hage; at the University Hospital of Ghent in Belgium under the direction of Drs Stan Monstrey and Griet DeCuypere; and in Belgrade, Serbia under the leadership of Dr Sava Perovic and his protégés, Drs Miro Djordjevic and Rados Djinovic. These esteemed and dedicated physicians have continued to advance the field of transgender medicine and surgery.
As a result of long-ongoing advocacy efforts, in May 2014, The US Department of Health and Human Services (HHS) repealed a 1989 decision declaring genital reconstruction surgeries for transsexualism “experimental.” The previous exclusion of gender-confirming surgeries was based on a 1981 report stating that “the safety and effectiveness of transsexual surgery had not been proven.” In the May 2014 ruling, HHS ruled that “…new evidence indicates that the…rationale for considering the surgery experimental is not valid…[and] new evidence indicates that transsexual surgery is a safe and effective treatment option for transsexualism in appropriate cases.” Following this, access to care was opened for Medicare beneficiaries.
However, it is Caitlyn Jenner, formerly Bruce, who recently has done more to advance the cause of individuals suffering from gender dysphoria than any other single person. Jenner won the gold medal in the men’s decathlon in the 1974 Olympics, giving her the unofficial title of the “world’s greatest athlete.” Jenner then went on to a successful career in TV and media, including starring in the reality show, “Keeping up with the Kardashians.” In 2015, Jenner announced publicly she is transgender. The generally positive media coverage has served to raise awareness as to the challenges facing this population.