In 1976, a woman from Roanoke, Virginia, named Rhoda got a prescription for two drugs: estrogen and progestin. Twelve months later, a local reporter noticed Rhoda’s surprisingly soft skin and visible breasts. He wrote that the drugs had made her “so completely feminine.”
That was indeed 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 we would call gender-affirming care these days—for years.
The founder of that clinic, Dr Milton Edgerton, had gritted his teeth caring for transgender people at Johns Hopkins University in the 1960s. There he was part of a team that founded the country’s first university gender identity clinic in 1966.
When politicians consider gender-affirming care as new these days, “not tested” or “experimentalthey ignore the long history of transgender medicine in the United States.
It’s been almost 60 years since the first transgender medical clinic opened in the US, and 47 years since Rhoda started her hormone therapy. Understanding the history of these treatments in the US can be a useful guide for citizens and legislators in a year in which a record number of bills in state houses focus on transgender rights.
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Treating gender in any population
As a trans woman and a scholar of transgender historyI’ve spent much of the past decade studying these issues. I also take different pills every morning to maintain the correct hormonal balance in my body: spironolactone to suppress testosterone and estradiol to increase estrogen.
When I started HRT or hormone replacement therapy, I, like many Americans, did not know that this treatment had been around for generations. What surprised me even more was that HRT is often prescribed to cisgender women—women who were designated female at birth and raised female all their lives. In fact, many providers in my area already had one long history of prescribing hormones to cis womenmainly women who are going through the menopause.
I also learned that gender-affirming hormone therapies have been prescribed to cisgender youth for generations—despite what contemporary politicians might think. Disability scientist Eli Clare has written about the history and ongoing practice of disability prescribe 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 shortness in women, doctors, parents, and ethicists have approved the use of hormonal therapies to make children conform to these gender stereotypes at least since 1940.
Clare describes a severely disabled young woman whose parents – with the approval of doctors and ethicists at their local children’s hospital – administered puberty blockers so that she would never grow up. They deemed her mentally incapable of becoming a “real” woman.
The history of these treatments shows that hormone therapies and puberty blockers have been used on cisgender children in this country – for better or for worse – with the aim of regulating the transition from girls to women and from boys to men. Gender stereotypes regarding the presence or absence of secondary sex characteristics—too long, too short, too much body hair—have all led parents and physicians to provide gender-affirming care to cisgender children.
For more than half a century, legal and medical authorities in the US have also approved and performed surgeries and hormone therapies to force the bodies of intersex children to conform to binary gender stereotypes. I myself underwent genital surgery as a child to bring my anatomy into line with expectations for what a “male” body should look like. In most cases, intersex surgeries are superfluous for the health or wellbeing of a child.
Historians such as Jules Gill-Peterson have demonstrated this early advances in transgender medicine in this country are deeply intertwined with the non-consensual treatment of intersex children. Doctors at Johns Hopkins and the University of Virginia practiced reconstructing the genitalia of intersex people before applying the same treatments to transgender patients.
Given these intertwined histories, I argue that the current political focus on banning gender-affirming care for transgender people is evidence that opposition to these treatments is not about the safety of specific drugs or procedures, but rather their specific use by transgender people .
How transgender people access healthcare
Many transgender people in the US have deeply complicated feelings about gender-affirming care. This complexity is the result of more than half a century of transgender medicine and patient experiences in the US
In Rhoda’s day, medical gatekeeping meant living “full-time” as a woman and proving her eligibility for gender-affirming care to a team of mostly white cis-male doctors before they would treat her. She had to mimic the language about ‘being’born in the wrong body” – language coined by cis doctors who study transgender people, not transgender people themselves. She had to confirm she would be heterosexual and seek marriage and monogamy with a man. She couldn’t be lesbian or bisexual or promiscuous.
Many transgender people today still have to jump through similar hoops to get gender-affirming care. For example, a diagnosis of “gender dysphoria‘, a designated mental disorder, is sometimes required before treatment. Many trans people believe 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 criticized the role of medical authority in gender-affirming care. Writer Janice Raymond condemned “the transsexual realm”, her term for the doctors, psychologists and other professionals who practice transgender medicine. Raymond argued that male cis doctors formed an army of trans women to gratify the male gaze: promoting iterations of femininity that reinforced sexist gender stereotypes, ultimately leading to the displacement and extermination of “biological” women from the world. The origins of today’s gender-critical or trans-exclusive radical feminist movement can be seen in Raymond’s words. But as trans scholar Sandy Stone wrote in her famous answer to Raymondit’s not that trans women are unwilling dupes of cis male medical authority, but rather that we need to strategically exercise our femininity in certain ways in order 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 legislators are introducing bills to ban gender-affirming care – even for adults – in ignorance of history. The ramifications of rushed legislation extend beyond transgender people, as access to hormones and surgery is a basic medical service that many people may need to feel better about their bodies.
A ban on hormone therapy and gender-related surgeries for minors could mean stopping the same treatment options for cisgender children. The legal implications for intersex children collide directly proposed legislation in several states which aims to codify “male” and “female” as separate biological genera with certain anatomical features.
A ban on hormone replacement therapy for adults could affect access to the same treatments for menopausal women or limit access to hormonal contraception. Bans on gender-confirming surgeries can affect a person’s ability to do so access to a hysterectomy or a mastectomy. So-called cosmetic surgeries such as breast implants or reductions, and even facial feminization such as lip fillers or Botox, may also be questioned.
These are all different types of gender affirming procedures. Are most Americans willing to live with this level of government interference in their bodily autonomy?
Almost all large medical organization in the US has resisted new government restrictions on gender-affirming care because, as doctors and professionals, they know these treatments proven and safe. These treatments have a history going back more than 50 years.
Trans and intersex people are important voices in this debate because our bodies are the politicians most often opposed to gender-affirming care treat them as objects of ridicule and disgust. Lawmakers develop policies about us despite the fact that most Americans say so don’t even know a trans person.
But trans and intersex people know what it’s like have to fight to get access to 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.
