History Moving Backwards: A Timeline of Trans Healthcare

Costume party at the Institute for Sexual Research in Berlin. Magnus Hirschfeld (in glasses) holds hands with his partner, Karl Giese (center). Magnus-Hirschfeld-Gesellschaft e.V., Berlin

Nora’s scared. She doesn’t know what’s going to happen to her hormones. Can she even get refills? She’s looking in the mirror, and the light’s playing tricks on her eyes. She’s seeing a face she hasn’t seen in years. It’s the warped mirror of dysphoria. The features are changing. The breasts are gone. On her face, the softness becomes hard. It’s her as a boy, her before she transitioned. Her mental health is sent reeling backward, thinking about limits to her access to healthcare. Nora has an uncertain future in Donald Trump’s America.

Nora isn’t a real person. She’s fictionalized for this article, but she represents a very real, non-fiction fact-of-life facing so many trans people right now. Today, trans people are up against President Trump and conservative America’s promise of policy restrictions or prohibitions to trans healthcare.

While President Trump was on the campaign trail, he said, “On Day 1, I will sign an executive order instructing every federal agency to cease the promotion of sex or gender transition at any age. They’re not going to do it anymore.” On the day of his inauguration, he signed an executive order rolling back some protections for trans people. Trans healthcare hasn’t yet been singled out, but many are worried about how far this campaign promise will extend. It’s scary to think what else will happen to trans-Americans. 


There have been some victories for trans healthcare over the past 100 years and some progress. Playwright Tony Kushner said, in his famous work ‘Angels in America,’ that “In this world, there is a kind of painful progress. Longing for what we’ve left behind and dreaming ahead.” Progress for trans people often comes in increments–a leap forward, and then a fall backward–in what I’d call “two steps forward, one step back,” to misquote the expression. And Kushner was right. It is a painful progress. It’s usually driven forward by science and medicine, then kicked back by policy and politics.

Being trans is not new and trendy, as many within the Republican Party would have you think. It’s not just some hot topic. It’s real American people’s lives. And there’s definitely nothing new about it. It’s been around for a while.

The Institute for Sexual Science. Historical postcard, 1920s. Archiv der Magnus-Hirschfeld-Gesellschaft e.V., Berlin

The first strides forward in trans healthcare began in Berlin, Germany in 1919, when gay and Jewish medical doctor Magnus Hirschfeld established the Institut für Sexualwissenschaft, or The Institute for Sexual Research. Its purpose was to be a place of “research, teaching, healing, and refuge.”

Hirschfeld began non-judgmental, objective research on members of the LGBTQ community, identifying early terms for trans people and a “third gender” that we would eventually come to call nonbinary or gender-nonconforming today. He even reported on the practice of bisexuality or pansexuality among those in the LGBTQ community and the idea that sexuality is a spectrum. “Love,” Hirschfeld said, “is as varied as people are.”

While in contrast, many colleagues and contemporaries considered homosexuality to be pathological, using the study of psychology at the time to deem it a mental illness. However, Hirschfeld’s conclusions argued it was naturally occurring. His research bore out depths and layers to people in our community. It illustrated them much more fully than the simple, catch-all, almost pejorative label his contemporaries used, homosexuell, or homosexual. And Hirschfeld’s research stood the test of time, unlike his contemporaries.

Hirschfeld’s most powerful and lasting research was into gender-affirming care for trans people.

He began studies into what he then termed “transvestites”– a group he divided into two types–those who wanted to wear clothes of the opposite sex and those who “from the point of view of the character” were the opposite sex. One soldier Hirschfeld worked with called wearing women’s clothing the ability “to be a human being for at least a moment.”

Soon, Hirschfeld would recruit gynecologist Ludwig Levy-Lenz and surgeon Erwin Gohrbrant, who together in 1930 would perform the first male-to-female (MTF) surgical transition on patient Dora Richter.

Dora Rudolfine Richter.

Although many more transition surgeries followed, the 1930s were a time of upheaval in Germany, and the institute became a target for the growing Nazi Party. Queer and transgender people were coming under fire in the Nazi Party’s larger campaign of so-called “un-German” ideas and “traditional values.”

In an echo of the Right Wing politics today, a large opposition within Germany’s conservative society attempted to undermine the institute and Hirschfeld, accusing the institute of promoting “degeneracy.” Soon, fascism would get the better of the institute. Two steps forward, one step back.

In January of 1933, upon Hitler’s rise to power, Hirschfeld fled Germany. Not long after, in May of 1933, the Nazis raided the institute. In a public square near the building, the Nazis gathered all that remained of Hirschfeld’s invaluable research, along with many forward-thinking books from the institute’s library. They burned it all. This would be the Nazi’s first major public book burning but not the last. Until September 2024, Dora Richter was presumed dead or missing since the raid in May 1933. Painstaking research by trans history researcher Clara Hartmann found that Dora escaped Germany, survived the war, and lived until she was 74.

Nazis burning books from Magnus Hirschfeld Institute for Sexual Research.

The Nazis’ reach extended far beyond the institute. They singled out trans people as one of the many groups they identified as “degenerates,” with many being arrested, imprisoned, and sent to concentration camps. And Hirschfeld’s ideas were silenced and nearly forgotten … for a time.


The next pioneering steps forward were in 1966 when Johns Hopkins Gender Clinic opened its doors to trans individuals. The Hopkins Clinic was among the first in the U.S. to provide gender-affirming care, taking a comprehensive approach that emphasized psychological counseling alongside gender-affirming surgeries.

Initially, the clinic did not seek attention, attempting to quietly perform transition surgeries to see if the staff’s techniques were effective. The New York Daily News “discovered” the clinic’s first patient, described as a “stunning girl who admits she was a male less than one year ago.” Sensationalist news stories followed in the media. In an attempt to present their side of the story, the clinic reached out to Thomas Buckley, a sympathetic reporter at the New York Times. The result was a front-page story that was reasonably, for the time, sensitive to trans people.

Now, the Hopkins Clinic had gained either fame or notoriety, depending on which media outlet you saw them on. Soon, their popularity got them a waiting list of over 100 trans people seeking care and transitions. Under the sheer number of applicants, the clinic was able to be extremely selective–going beyond seeking those with the best health psychologically to seeking out applicants who were attractive physically. If a patient wanted to transition from male to female, doctors would rule out taller, more masculine candidates in favor of patients who were more feminine to give themselves more attractive results. Perhaps the clinic considered these optics necessary at the time, but these practices left many at-risk trans people uncared for. 

The clinics had a comprehensive approach to gender-affirming care–counseling, hormone therapy, and gender-affirming surgeries–and even had an innovative prerequisite to care known as the “Real-Life Test,” where patients would live and dress as their transgender before treatment. The Hopkins Clinic continued performing gender-affirming care and surgeries for over a decade.

However, progress stopped moving forward in 1979, when Dr. Paul McHugh was appointed director of psychiatry at Johns Hopkins and decided to close the gender clinic. His views were much more conservative and less open-minded, and he argued the clinic was promoting the mental illness of patients choosing to transition. This view confounded other doctors’ research at the clinic, with one study showing that all but one of 24 patients who had transitioned said their lives had changed for the better. However, the clinic fell victim to the pervasive ideology of those like McHugh.

Coverage in the New York Times about the clinic’s closing gave voice to those like McHugh’s. If you look closely, it seems eerily close to media coverage today. 

The John Hopkins Gender Clinic’s legacy lived on. By its closing, only 30 gender-affirming surgeries had been performed there, but doctors at the clinic had consulted on more than 1000 other surgeries at other hospitals, training new doctors in their gender-affirming surgeries. Even though conservative ideology had snuffed out the clinic, between 15 and 20 other medical centers were already performing surgeries at its end.


In the following years, the cause of trans healthcare continued to decline amidst conservative ideology.  In the 1980s, a Regan-Era Department of Health and Human Services determined gender-affirming care was “experimental”. It would not be covered under federal insurance programs such as Medicare and Medicaid. The government took the lead, and private insurance programs followed, also not covering trans healthcare. 

You can’t talk about access to gender-affirming care without talking about insurance. Most trans individuals can’t privately fund their healthcare, so barriers to care by insurance could mean no care at all. While gender-affirming care was deemed “experimental” at the time, there was also no federal funding for much-needed studies to evaluate the actual efficacy of such care–a Catch-22.

In recent years, there had been a positive shift forward for trans healthcare. In 2010, Obamacare provided some protections. In 2016, the federal government removed the “experimental” designation, and the Department of Health and Human Services required some gender-affirming care to be provided by Medicare. Medicaid is state-run and varies by state. Private insurance companies vary on coverage, but most cover some form of gender-affirming care, such as hormone therapy. But with President Trump in office, a mostly Republican congress, a majority conservative Supreme Court, and a growing anti-Trans ideology and rhetoric among the President’s sympathizers, these protections could be changing, leaving many at risk.

By executive order, President Trump declared that the U.S. would recognize only two genders, male and female and that it would not recognize changes to gender.


Advancements in trans healthcare are driven forward by science, medicine, and psychology–then, they’re hindered, weighed down, or outright undermined by policy and politics. For trans individuals, the science and research are in, and they’ve been in for a while. Gender-affirming care–counseling, hormone therapy, and gender-affirming surgeries–is the gold standard treatment for gender dysphoria. Gender-affirming care has been endorsed by every major medical association in the U.S.: The American Medical Association, The American Psychological Association, The American Academy of Pediatrics, The World Professional Association of Transgender Health, and The Endocrine Society. 

Numerous studies have shown that gender-affirming care can improve mental health and lower the risk of suicidal thoughts and suicide attempts. Simply put, it saves lives. 

Efforts to bar access to gender-affirming care for trans people aren’t just ill-advised medically; it’s dehumanizing. It’s a de facto statement that they don’t have the right to exist and live. President Trump has rallied his conservative base in support of these trans healthcare restrictions, and what this overwhelming majority of red voters are saying to the small minority of the about 1% of people in the U.S. that are trans is that you’re outnumbered and we can bully you into not existing.

Don’t think that Nazi Germany was an anomaly, like some horrible, terrible one-off. Learn from its lessons. The Institute for Sexual Research fell victim to an ideology–what was then the crazed fervor of Nationalism and “traditional values” in Germany. You can draw a parallel between that and another ideology: the rising anti-trans ideology and fervor within the Republican Party today, still rooted in Nationalism and “traditional values.”

To repeat a sentiment often spoken about the Holocaust, “Never again.”

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Ryan Dancho is a writer and artist. He escaped the cow-and-cornfield madness of small-town Pennsylvania only to move several hours to left to Pittsburgh, the big city. Bi-guy and mental health advocate.