‘History is repeating itself’: The story of the nation’s first clinic for gender-affirming surgery

Nearly 60 years ago, Johns Hopkins Hospital opened a first-of-its-kind clinic to provide gender-affirming surgery. The Gender Identity Clinic blazed a new trail, with more than a dozen new clinics opening across the country in the decade that followed.

But in 1979, the clinic shut its doors. And while the institution claimed for years that the decision was made based on the evidence — which, they argued, showed such surgeries didn’t benefit patients — new research by a Johns Hopkins medical school student reveals a different story. The student, Walker Magrath, dug through years of archived correspondence and notes at both Johns Hopkins and Harvard University, and found that internal politics and pushback from hospital leadership ultimately caused the clinic to close.

“It’s important for Johns Hopkins as an institution to reckon with its harmful history with LGBTQ patients,” said  Magrath,who authored a new paper documenting the history of the center published Monday in Annals of Internal Medicine. For decades after the center closed, Johns Hopkins didn’t provide gender-affirming surgeries for trans patients — but it recently opened a center for transgender care.

In light of recent threats made to hospitals that provide gender-affirming care to trans patients and the closures of gender-affirming and reproductive health clinics across the country over the last year, Magrath felt that it was critical to make clear that this isn’t the first time gender-affirming clinics have faced backlash and closures.

“We need to be critical of mainstream medical institutions that wield a lot of power because their influence causes a [ripple] effect,” Magrath said. When the clinic at Johns Hopkins closed, others around the country began to shutter too. While there were 20 similar clinics in 1979, only two or three were still operating by the mid-1990s, according to Magrath.

“History is repeating itself,” said Alex Keuroghlian, of Massachusetts General Hospital and the Fenway Institute, who co-authored an editorial on Magrath’s paper with Asa Radix, of New York University and the Callen-Lorde Community Health Center. “We’re seeing the exact same tactics being used — defamation, sensationalist transphobia, intimidation of providers who want to offer this care,” Keuroghlian said.

Magrath found documentation that showed the clinic was met with bias and stigma from hospital leaders such as Paul McHugh, who became the hospital’s chief of psychiatry in 1975. McHugh arrived at Hopkins intending to stop gender-affirming surgery, according to Magrath. But Magrath also noted that McHugh, known for his pathologizing and homophobic statements on LGBTQ+ health, is just one of many leaders at the institution who fought against the clinic’s mission.

John Hoopes, the hospital’s chief of plastic surgery while the clinic operated, originally supported gender-affirming surgery and served as the GIC’s inaugural director, saying “there exists reasonably good evidence” that surgery could lead to positive results. But his opinions adapted as plastic surgery became a higher-profile specialty, leaving him worried that the slower progress around gender-affirming surgery would become a liability to his department. He later described transgender patients as “hysterical,” “freakish,” and “artificial.” Years before the closure, Hoopes ordered that the GIC be separated from the surgery department, depriving the clinic of valuable resources and leaving its physicians to operate under obstetrics department, which was mired in its own set of controversies that made it difficult to support the GIC’s work.

When the clinic closed, the mainstream narrative was that research performed at Johns Hopkins had concluded that gender-affirmative surgery had no advantage for patients’ “social rehabilitation.” But the methods of the study were swiftly questioned by experts, who noted the conclusions may be unreasonable based on the statistics used. Magrath notes that the sample of patients included in that study were those treated in  the earliest days of the clinic’s work, when surgical techniques were new and evolving. The clinic’s co-founder, psychologist John Money, admitted that some of those early cases were not successful, but was never given funding to do his own follow-up research.

In their accompanying editorial, Keuroghlian and Radix also point out that the metrics that researchers used to define rehabilitation focused more on fitting trans people into a limited, traditional model of success, rather than measuring their actual well-being.

“Studies are often used to fuel political agendas,” Magrath said. “Science often can be manipulated, and you can see that in our modern society.” It happened decades ago when the GIC was closed, he noted, and it’s happening now as pressure builds on facilities that provide gender-affirming care.

Historically, marginalized communities like trans and nonbinary people haven’t been included in providing care for their own communities, said Keuroghlian, who helps to train physicians across the country to provide gender-affirming care as part of their work at the Fenway Institute. This was part of the problem with the GIC, they said.

“There was a real paternalism to how decisions were made by leadership, which is how a lot of medicine is characterized,” Keuroghlian said.

The health system still has  a service in the Department of Plastic Surgery at Johns Hopkins named after Hoopes, and McHugh is still listed as a University Distinguished Service Professor on the institution’s website.

Liz Vandendriessche, a spokesperson for Johns Hopkins, said that while the institution supports its community members sharing their perspectives, the paper represents only Magrath’s personal opinion. She added that the hospital’s Center for Transgender Health provides care in line with the standards from the World Professional Association for Transgender Health.

To Keuroghlian and Magrath, there’s a need for more accountability from leading institutions like Johns Hopkins, which help to set the standard for health care.

“If our major, well-resourced academic teaching hospitals don’t set the example of providing care for the most marginalized in our communities, and don’t lead with health equity and social justice as organizing principles, then nobody else is going to do it,” Keuroghlian said.

This story has been updated to include a statement from a Johns Hopkins Medicine spokesperson.