The Early Landscape of Gender Affirmation Surgery in the United States

Gender affirmation surgeries (GASs) are procedures that help patients align their body and gender identity. European surgeons are widely credited with pioneering GAS surgical techniques in the 1930s, whereas knowledge of GAS in the United States (US) prior to the 1960s is sparser. This study explores the early leaders, techniques, and obstacles encountered by physicians performing GAS in the US in the 1950s to 1970s.

Archives from the Harry Benjamin Collection and Elmer Belt Papers were reviewed for patient, physician, and operative details.

A total of 39 physician and academic collaborators and 72 patients were identified. Most physicians and academic collaborators were from the US (28/39, 71.8%) or Germany (3/39, 7.7%). Urology was the most common specialty (8/36, 22.2%), followed by plastic surgery (7/36, 19.4%) and psychiatry (5/36, 13.9%). Forty patients underwent GAS, of which the majority underwent vaginoplasty (31/40, 77.5%), orchiectomy (7/40, 17.5%), and penectomy without vaginoplasty (4/40, 10.0%). Belt preferred to implant testicles into the retroperitoneum rather than perform orchiectomies during his vaginoplasties, and vaginoplasty complications were commonly reported (13/31, 41.9%). Patients and providers faced challenges obtaining and providing GAS due to the indeterminate legal status of the procedures, shifting hospital policies, and discouragement from family and colleagues.

Despite records of professional, familial, and even legal censure, the legacy of these early physicians and patients persists in the continued practice and refinement of GAS surgical techniques, often through the same organizations that housed these early practitioners. This article seeks to deepen our understanding of the lives and professional struggles of these medical innovators, upon whose work the contemporary American practice of GAS is built.