Hopkins Hospital: a history of sex reassignment

In 1965, the Hopkins Hospital became the first academic institution in the United States to perform sex reassignment surgeries. Now also known by names like genital reconstruction surgery and sex realignment surgery, the procedures were perceived as radical and attracted attention from The New York Times and tabloids alike. But they were conducted for experimental, not political, reasons. Regardless, as the first place in the country where doctors and researchers could go to learn about sex reassignment surgery, Hopkins became the model for other institutions. But in 1979, Hopkins stopped performing the surgeries and never resumed.

In the 1960s, the idea to attempt the procedures came primarily from psychologist John Money and surgeon Claude Migeon, who were already treating intersex children, who, often due to chromosome variations, possess genitalia that is neither typically male nor typically female. Money and Migeon were searching for a way to assign a gender to these children, and concluded that it would be easiest if they could do reconstructive surgery on the patients to make them appear female from the outside. At the time, the children usually didn’t undergo genetic testing, and the doctors wanted to see if they could be brought up female.

“[Money] raised the legitimate question: ‘Can gender identity be created essentially socially?’ … Nurture trumping nature,” said Chester Schmidt, who performed psychiatric exams on the surgery candidates in the 60s and 70s.

This theory ended up backfiring on Money, most famously in the case of David Reimer, who was raised as a girl under the supervision of Money after a botched circumcision and later committed suicide after years of depression.

However, at the time, this research led Money to develop an interest in how gender identities were formed. He thought that performing surgery to match one’s sex to one’s gender identity could produce better results than just providing these patients with therapy.

“Money, in understanding that gender was — at least partially — socially constructed, was open to the fact that [transgender] women’s minds had been molded to become female, and if the mind could be manipulated, then so could the rest of the body,” Dana Beyer, Executive Director of Gender Rights Maryland, who came to Hopkins to consider the surgery in the 70s, wrote in an email to The News-Letter.

Surgeon Milton Edgerton, who was the head of the University’s plastic surgery unit, also took an interest in sex reassignment surgery after he encountered patients requesting genital surgery. In 2007, he told Baltimore Style: “I was puzzled by the problem and yet touched by the sincerity of the request.”

Edgerton’s curiosity and his plastic surgery experience, along with Money’s interest in psychology and Migeon’s knowledge of plastic surgery, allowed the three to form a surgery unit that incorporated other Hopkins surgeons at different times. With the University’s approval, they started performing sex reassignment surgeries and created the Gender Identity Clinic to investigate whether the surgeries were beneficial.

“This program, including the surgery, is investigational,” plastic surgeon John Hoopes, who was the head of the Gender Identity Clinic, told The New York Times in 1966. “The most important result of our efforts will be to determine precisely what constitutes a transsexual and what makes him remain that way.”

To determine if a person was an acceptable candidate for surgery, patients underwent a psychiatric evaluation, took gender hormones and lived and dressed as their preferred gender. The surgery and hospital care cost around $1500 at the time, according to The New York Times.

Beyer found the screening process to be invasive when she came to Hopkins to consider the surgery. She first heard that Hopkins was performing sex reassignment surgeries when she was 14 and read about them in Time and Newsweek.

“That was the time that I finally was able to put a name on who I was and realized that something could be done,” she said. “That was a very important milestone in my consciousness, in understanding who I was.”

When Beyer arrived at Hopkins, the entrance forms she had to fill out were focused on sexuality instead of sexual identity. She says she felt as if they only wanted to consider hyper-feminine candidates for the surgery, so she decided not to stay. She had her surgery decades later in 2003 in Trinidad, Colo.

“It was so highly sexualized, which was not at all my experience, certainly not the reason I was going to Hopkins to consider transition, that I just got up and left, I didn’t want anything to do with it,” she said. “No one said this explicitly, but they certainly implied it, that the whole purpose of this was to get a vagina so you could be penetrated by a penis.”

Beyer thinks that it was very important that the transgender community had access to this program at the time. However, she thinks that the experimental nature of the program was detrimental to its longevity.

“It had negative consequences because when it was done it was clearly experimental,” she said. “Our opponents were able to use the experimental nature of the surgery in the 60s and the 70s against us.”

By the mid-70s, fewer patients were being operated on, and many changes were made to the surgery and psychiatry departments, according to Schmidt, who was also a founder of the Sexual Behaviors Consultation Unit (SBCU) at the time. The new department members were not as supportive of the surgeries.

In 1979, SBCU Chair Jon Meyer conducted a study comparing 29 patients who had the surgery and 21 who didn’t, and concluded that those who had the surgery were not more adjusted to society than those who did not have the surgery. Meyer told The New York Times in 1979: “My personal feeling is that surgery is not proper treatment for a psychiatric disorder, and it’s clear to me that these patients have severe psychological problems that don’t go away following surgery.”

After Meyer’s study was published, Paul McHugh, the Psychiatrist-in-Chief at Hopkins Hospital who never supported the University offering the surgeries according to Schmidt, shut the program down.

Meyer’s study came after a study conducted by Money, which concluded that all but one out of 24 patients were sure that they had made the right decision, 12 had improved their occupational status and 10 had married for the first time. Beyer believes that officials at Hopkins just wanted an excuse to end the program, so they cited Meyer’s study.

“The people at Hopkins who are naturally very conservative anyway … decided that they were embarrassed by this program and wanted to shut it down,” she said.

A 1979 New York Times article also states that not everyone was convinced by Meyer’s study and that other doctors claimed that it was “seriously flawed in its methods and statistics and draws unwarranted conclusions.”

However, McHugh says that it shouldn’t be surprising that Hopkins discontinued the surgeries, and that he still supports this decision today. He points to Meyer’s study as well as a 2011 Swedish study that states that the risk of suicide was higher for people who had the surgery versus the general population.

McHugh says that more research has to be conducted before a surgery with such a high risk should be performed, especially because he does not think the surgery is necessary.

“It’s remarkable when a biological male or female requests the ablation of their sexual reproductive organs when they are normal,” he said. “These are perfectly normal tissue. This is not pathology.”

Beyer, however, cites a study from 1992 that shows that 98.5 percent of patients who underwent male-to-female surgery and 99 percent of patients who underwent female-to-male surgery had no regrets.

“It was clear to me at the time that [McHugh] was conflating sexual orientation and the actual physical act with gender identity,” Beyer said.

However, she thinks that shutting down the surgeries at Hopkins actually helped more people gain access to them, because now the surgeries are privatized.

“Paul McHugh did the trans community a very big favor … Privatization [helps] far more people than the alternative of keeping it locked down in an academic institution which forced trans women to jump through many hoops.”

Twenty major medical institutions offered sex reassignment surgery at the time that Hopkins shut its program down, according to a 1979 AP article.

Though the surgeries at Hopkins ended in 1979, the University continued to study sexual and gender behavior. Today, the SBCU provides consultations for members of the transgender community interested in sex reassignment surgery, provides patients with hormones and refers patients to specialists for surgery.

The Hopkins Student Health and Wellness Center is also working toward providing transgender students necessary services as a plan benefit under the University’s insurance plan once the student health insurance plan switches carriers on Aug. 15.

“We are hopefully working towards getting hormones and other surgical options covered by the student health insurance,” Demere Woolway, director of LGBTQ Life at Hopkins, said. “We’ve done a number of trainings for the folks over in the Health Center both on the counseling side and on the medical side. So we’ve done some great work with them and I think they are in a good place to be welcoming and supportive of folks.”

Schmidt does ongoing work to provide the Hopkins population with transgender services, and says he would like for Hopkins to start performing sex reassignment surgeries again. But Chris Kraft, the current co-director of the SBCU, says that this is not feasible today, as no academic institution provides these surgeries since not enough people request them.

“It is unfortunate that no medical schools in the country have faculty who are trained or able to provide surgeries,” he wrote in an email to The News-Letter. “All the best surgeons work free-standing, away from medical schools. If we had surgeons who could provide the same quality services as the other surgeons in the country, then it would make sense to provide these services. Sadly, few physicians are willing to make gender surgery a priority in their careers because gender patients who go on to surgery are a very small population.”

Beyer, however, does not think that the transgender community needs Hopkins to reinstate its program, and that there are currently enough options available.

“We’re way, way past that,” she said. “It’s no longer the kind of procedure that needs an academic institution to perform research and development.”

Though she finds the way that Hopkins treated its sex reassignment patients in the 60s and 70s questionable, she thinks that the SBCU has been a great resource for the transgender community.

“Today those folks are wonderful people,” Beyer said. “They’re very helpful. They’re the go-to place up in Baltimore. They’ve done a lot of good for a lot of people. They’ve contributed politically as well to passage of gender identity legislation in Maryland and elsewhere.”

The Maryland Coalition for Trans Equality’s Donna Cartwright said that the transgender community does not have enough resources available to them. She said offering surgery at a nearby academic institution could provide more support to the community.

“Generally, the medical community needs to be better educated on trans health care and there should be greater availability [of sex reassignment surgery],” she said. “I think it would be good if there was an institution in the area that did provide health care, including surgery.”

19 Responses to "Hopkins Hospital: a history of sex reassignment"

  1. SJNMom   May 1, 2014 at 1:57 pm

    As a resident I had a pt who had under gone transgender surgery and was touted as the success. She did a lot of media interviews. However she would often cry and say to me-” Now I’m neither male or female”. How sad. I think the transgender surgeries should be stopped.

    No one wants to tell the truth. I have not only heard that from that first patient but others since that time.

    What in the world are we doing, cutting away normal organs, giving hormones, trying to make some-one something they are not.

    Inevitably, life (through the transgender “woman” getting a male disease such as prostate cancer or other such thing) reality weighs down and these folks are more unhappy then ever.

    Now it is not politically correct that research should show the truth so no one will do or report the real research.

    How sad it is that we have let political and not moral correctness reign in this arena.

  2. Dallas Denny   May 2, 2014 at 2:45 pm

    So, SJNMom, you’re making your clinical decision based upon an n of one? Or maybe five? And from such a font of knowledge you wish to ban the surgeries? Please cancel my appointment.

    • James Campbell   August 22, 2014 at 3:55 pm

      So, on the basis of ONE anecdotal account, all reassignment surgeries should be stopped? Perhaps we could extend this non-medical approach to heart surgery – one death and all cardiac surgeries are forbidden.

      As a doctor who works with children and young people (theousands NOT just one individual), some of whom present with gender dysphoria,I support the surgical approach for a medically determined diagnosis. Statisitcs show that surgery is far more successful than counselling alone.

      Johns Hopkins has NOT ceased to offer reassignment surgery – private patients are still receiving treatment.

      • Bo   September 25, 2014 at 7:19 am

        James, could you please link me to these statistics? The one that you say, “show that surgery is far more successful than counseling[sic] alone”? I am looking into this issue as a whole(from a practical, non-bias standpoint), and from what I have found so far, it seems like the opposite is true. But I want an honest, balanced opinion. I’d really appreciate it! Thanks.

        • chyeah   June 2, 2015 at 9:56 pm

          No answer was the loud reply. I guess they really had no actual research or statistics to give you. Idealogues never do.

  3. Chloe Alexa Landry   May 2, 2014 at 4:11 pm

    What John’s Hopkins did was akin to the experimental work the Nazi Doctors did during the war. Led by John Money a false Assumption was chosen to seemingly right some bodily errors. Later in the 60’s Money found the Twin boys in Canada and started with them to pursue his theories of nurture over nature. He even used Trans people to show it would work. At same time frame another doctor was working on Gender studies whom Money did much to alienate his work and research, a Dr. Milton Diamond.

    Dr Money never interviewed his Trans people very well as too when they knew that they were Trans. I for one knew at three years old. Others as soon as 2 before they could talk. Had He done that simple thing his theories would have failed before they started. His practices are still being practiced all over the world and many examples of failure can and are documented. A court case in Virginia Beach I believe is in order presently with a little boy. Intersex should not be designated one sex or the other except in a medical lifesaving event. They should Choose
    when they are of age.

    You wrote: “The people at Hopkins who are naturally very conservative anyway … decided that they were embarrassed by this program and wanted to shut it down,” Rightly so, then why did they start it without proper research??

    You also wrote:
    Schmidt does ongoing work to provide the Hopkins population with transgender services, and says he would like for Hopkins to start performing sex reassignment surgeries again. But Chris Kraft, the current co-director of the SBCU, says that this is not feasible today, as no academic institution provides these surgeries since not enough people request them.

    If so why are so many University’s and corporations paying for this surgery. There would be many more because most cannot afford the cost. This will change and John’s Hopkins will have Missed the Boat again.

    What Dr. Money did to Intersex people was Criminal and it continues today from your Hospitals Legacy! !
    His programs made it to Minneapolis also. Bad results.

    • Wm Cobbett   March 15, 2015 at 3:32 pm

      Your invocation of the David Reimer case is ironic, since the case clearly illustrates that you CANNOT change a child’s inner sense of sexual (‘gender’) identity. This was generally known as the ‘John/Joan’ case before it was exposed by the Colapinto article and book.

      John Money was often wrongheaded and irresponsible, but he was on the same page as you and Paul McHugh: he believed you could mold and persuade people out of their gender identity. It is pretty clear that you can’t.

  4. Ron Low   May 2, 2014 at 10:25 pm

    How DARE the author not title this article “A SHAMEFUL History of Sexual Re-Assignment” ??

    Informed adults can decide for themselves at a rational age whether any of their parts are disposable.

    • Hegesippus   April 27, 2015 at 1:33 pm

      To claim the decision of having body parts that are disposable as being rational points to having been informed of some rather dubious thinking!

  5. Susanna Boudrie   May 2, 2014 at 11:49 pm

    Paul McHugh misinterprets Dr Cecilia Dehjne’s 2011 study to defend his ideology. However the study did not reach the conclusions he is falsely stating.

    • Bo   September 25, 2014 at 7:19 am

      Could you possibly elaborate?

      • chyeah   June 2, 2015 at 9:58 pm

        ever heard of google? yeah. you were given enough info to pull up tons on google scholar.

  6. Zoe Brain   May 4, 2014 at 12:46 am

    The Swedish study did indeed show that post-op Trans people had more problems than the general population.

    Similar studies on post-op cancer and heart patients show that morbidity and mortality is also increased compared to the general population. We cannot conclude that surgical treatment of cancer or heart patients is not useful, simply because outcome is not perfect. This is fairly basic science.

    In all those cases, including transsexuality, a proper trial with a control group who remain untreated would be unethical, due to the much higher mortality in the control group.

    I’m not surprised that Dr McHugh doesn’t see things that way. He openly admitted in his work “Psychiatric Misadventures” that

    “This interrelationship of cultural antinomianism and a psychiatric misplaced emphasis is seen at its grimmest in the practice known as sex-reassignment surgery. I happen to know about this because Johns Hopkins was one of the places in the United States where this practice was given its start. It was part of my intention, when I arrived in Baltimore in 1975, to help end it.”

    Verdict first, gathering evidence in support of the pre-determined ideological conclusion afterwards.

    “It was part of my intention, when I arrived in Baltimore in 1975, to help end it.”

    I can think of no more damning words for someone pretending to be engaged in research.

  7. Zoe Brain   May 4, 2014 at 1:23 am

    In Prof McHugh’s defence… data since then strongly suggests that Gender Identity is something determined before birth. It is not malleable.

    Where he goes badly awry is in his unevidenced assumption that it is determined purely by chromosomes through some unspecified mechanism, and that neuro-anatomy plays no role. Data strongly suggests the opposite.

    For example, in Cloacal Extrophy, neuro-anatomy only differs weakly from the usual course of events.

    Discordant Sexual Identity in Some Genetic Males with Cloacal Exstrophy Assigned to Female Sex at Birth by Reiner and Gearhart, N Engl J Med. 2004 January 22; 350(4): 333–341.
    RESULTS Eight of the 14 subjects assigned to female sex declared themselves male during the course of this study, whereas the 2 raised as males remained male. Subjects could be grouped according to their stated sexual identity. Five subjects were living as females; three were living with unclear sexual identity, although two of the three had declared themselves male; and eight were living as males, six of whom had reassigned themselves to male sex. All 16 subjects had moderate-to-marked interests and attitudes that were considered typical of males. Follow-up ranged from 34 to 98 months.
    CONCLUSIONS Routine neonatal assignment of genetic males to female sex because of severe phallic inadequacy can result in unpredictable sexual identification. Clinical interventions in such children should be reexamined in the light of these findings.

    No matter what you do post-natally, surgically or through upbringing, and despite the fact that neither sex nor gender identity are strict binaries, you can’t change a boy into a girl. Try, and some who are not strongly gendered can live with it, though even then they have “moderate-to-marked interests and attitudes that were considered typical of males”. Many *can’t* live with it though, despite the many societal, legal and medical barriers to transition.

    However this implies that there will inevitably be some whose external appearance and genital configuration appear usual, but whose neuro-anatomy is cross-sexed. What this proportion is, from negligible (1 in several million) to very significant (1 in several thousand) has to be determined empirically. Also to be determined, the behavioural and attitudinal effects, and since brains are anything but homogenous structures, which parts are affected and to what degree.

    Male-to-female transsexuals show sex-atypical hypothalamus activation when smelling odorous steroids. by Berglund et al Cerebral Cortex 2008 18(8):1900-1908;
    …the data implicate that transsexuality may be associated with sex-atypical physiological responses in specific hypothalamic circuits, possibly as a consequence of a variant neuronal differentiation.

    Male–to–female transsexuals have female neuron numbers in a limbic nucleus. Kruiver et al J Clin Endocrinol Metab (2000) 85:2034–2041
    The present findings of somatostatin neuronal sex differences in the BSTc and its sex reversal in the transsexual brain clearly support the paradigm that in transsexuals sexual differentiation of the brain and genitals may go into opposite directions and point to a neurobiological basis of gender identity disorder.

    A sex difference in the human brain and its relation to transsexuality. by Zhou et al Nature (1995) 378:68–70.
    Our study is the first to show a female brain structure in genetically male transsexuals and supports the hypothesis that gender identity develops as a result of an interaction between the developing brain and sex hormones

    A sex difference in the hypothalamic uncinate nucleus: relationship to gender identity. by Garcia-Falgueras et al Brain. 2008 Dec;131(Pt 12):3132-46.
    We propose that the sex reversal of the INAH3 in transsexual people is at least partly a marker of an early atypical sexual differentiation of the brain and that the changes in INAH3 and the BSTc may belong to a complex network that may structurally and functionally be related to gender identity.

    White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study. – Rametti et al, J Psychiatr Res. 2010 Jun 8.
    CONCLUSIONS: Our results show that the white matter microstructure pattern in untreated FtM transsexuals is closer to the pattern of subjects who share their gender identity (males) than those who share their biological sex (females). Our results provide evidence for an inherent difference in the brain structure of FtM transsexuals.

    Specific Cerebral Activation due to Visual Erotic Stimuli in Male-to-Female Transsexuals Compared with Male and Female Controls: An fMRI Study by Gizewski et al J Sex Med 2009;6:440–448.
    Results. Significantly enhanced activation for men compared with women was revealed in brain areas involved in erotic processing, i.e., the thalamus, the amygdala, and the orbitofrontal and insular cortex, whereas no specific activation for women was found. When comparing MTF transsexuals with male volunteers, activation patterns similar to female volunteers being compared with male volunteers were revealed. Sexual arousal was assessed using standard rating scales and did not differ significantly for the three groups.

    ..and so on.

    Prof McHugh’s pre-judgment that the issue is psychiatric, not biological, in nature, a product of sociology, is evidenced by another quote from “Psychiatric Misadventures”

    “We need to know how to prevent such sadness, indeed horror.We have to learn how to manage this condition as a mental disorder when we fail to prevent it. If it depends on child rearing, then let’s hear about its inner dynamics so that parents can be taught to guide their children properly. If it is an aspect of confusion tied to homosexuality, we need to understand its nature and exactly how to manage it as a manifestation of serious mental disorder among homosexual individuals. But instead of attempting to learn enough to accomplish these worthy goals, psychiatrists collaborated in a exercise of folly with distressed people during a time when “do your own thing” had something akin to the force of a command.”

    He ignores the 60 year history of wild-goose chases hunting for a post-natal environmental cause that doesn’t exist – it’s not as if they haven’t been looked for! What he proposes as “treatment that hasn’t been tried” was tried long ago – with unfortunate results.

    “Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success (Gelder & Marks, 1969; Greenson, 1964), particularly in the long term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965). Such treatment is no longer considered ethical. ” – Standards of care v7

    He also appears unaware of the many advances in neuro-imaging since the mid 90’s that contradict his unevidenced ideologically and politically based beliefs.

    • Bill Andrews   February 18, 2015 at 6:24 am

      An ‘inherent difference in brain structure’ is not necessarily a good argument for the health of how a person views themselves. Gender identity is not the only outlook a person has about themselves or life in general. Will you take the same stance for those who demonstrate an ‘inherent brain structure’ whose development leads to violent behavior or some other anomaly? You seem to be splitting hairs to make the exception into the rule.
      There are plenty of external factors that impact brain development in post’ natal years. If depression proneness, anxiety, PTSD, physical/emotional/sexual abuse do not impact a persons brain development or self-image then those issues should be made no issue at all.

  8. Cecilia Dhejne   May 4, 2014 at 4:12 pm

    Some clarifications regarding a study that was published in 2011 by myself and co-workers. The study showed a three times elevated hazard ration for overall mortality compared to the general population for the period 1973-2003 (i.e. the time period in the study).The main causes of death were suicide, cardiovascular disease and smoke related cancer. If the study period was divided to before or after 1989 it was evident that mortality after 1989 was not significantly different from the general population. The study was not designed to answer the question if gender confirming surgery imposed specific risks or benefits. Therefore the findings cannot be to argue for or against endocrine or surgical treatment. As pointed out earlier, the same type of outcome are observed for other diseases and no one would argue against treatment of cancer, diabetes or bipolar disorder; all demonstrate an increased overall mortality. The suggested conclusion is to focus on improvement in care. Gender confirmation surgery and endocrine treatment only aims at amelioration of gender dysphoria. Many studies and a meta-analysis confirms a decrease in gender dysphoria complaints. Individuals with gender dysphoria may also suffer from depression, PTSD, and also consequences from gender related abuse, sexual trauma, discrimination, and hate crimes. I do think we have to address these questions on a societal levels as well as in in the health care system in order to improve general health among those who suffer from gender dysphoria.

    • Bo   September 25, 2014 at 7:22 am

      Can you prove you are the person you say you are? I don’t mean to be rude, it just seems fishy to me. I’m sure you understand.

      • Michael Irons   December 4, 2014 at 5:33 pm

        I can jump in that one…

        Yes I can, so can you, as can anyone else. The question is not Unity of Identity. The question is the right and Wrong of SRS. Changing the subject is Avoiding the question with a Red Herring Fallacy. Points for trying though 🙂

  9. nel   April 27, 2015 at 4:07 pm

    you can hardly compare heart surgery with genital reassignment surgery which treats a psychological disorder with the deliberate, irreversible surgical destruction of healthy organs,at serious risk to health and function, for no reason other than cosmetic appearance and with little evidence that it makes any difference to suicide and pathology rates in those identifying as gender dysphoric. since when did extensive destructive medical treatments and unlimited validation become a reasonable response to threats of suicide and delusional conditions? I don’t think that works with any other mental illness does it? objecting to the labelling of gender dysphoria as a mental illness only erases all possibility of medically justifying treatment.


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