first gender reassignment surgery in the world

May 10, 2021

The Forgotten History of the World's First Trans Clinic

The Institute for Sexual Research in Berlin would be a century old if it hadn’t fallen victim to Nazi ideology

By Brandy Schillace

Costume party at the Institute for Sexual Research in Berlin, date and photographer unknown. Magnus Hirschfeld ( in glasses ) holds hands with his partner, Karl Giese ( center ).

Magnus-Hirschfeld-Gesellschaft e.V., Berlin

Late one night on the cusp of the 20th century, Magnus Hirschfeld, a young doctor, found a soldier on the doorstep of his practice in Germany. Distraught and agitated, the man had come to confess himself an Urning —a word used to refer to homosexual men. It explained the cover of darkness; to speak of such things was dangerous business. The infamous “Paragraph 175” in the German criminal code made homosexuality illegal; a man so accused could be stripped of his ranks and titles and thrown in jail.

Hirschfeld understood the soldier’s plight—he was himself both homosexual and Jewish—and did his best to comfort his patient. But the soldier had already made up his mind. It was the eve of his wedding, an event he could not face . Shortly after, he shot himself.

The soldier bequeathed his private papers to Hirschfeld, along with a letter: “The thought that you could contribute to [a future] when the German fatherland will think of us in more just terms,” he wrote, “sweetens the hour of death.” Hirschfeld would be forever haunted by this needless loss; the soldier had called himself a “curse,” fit only to die, because the expectations of heterosexual norms, reinforced by marriage and law, made no room for his kind. These heartbreaking stories, Hirschfeld wrote in The Sexual History of the World War , “bring before us the whole tragedy [in Germany]; what fatherland did they have, and for what freedom were they fighting?” In the aftermath of this lonely death, Hirschfeld left his medical practice and began a crusade for justice that would alter the course of queer history.

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Hirschfeld sought to specialize in sexual health, an area of growing interest. Many of his predecessors and colleagues believed that homosexuality was pathological, using new theories from psychology to suggest it was a sign of mental ill health. Hirschfeld, in contrast, argued that a person may be born with characteristics that did not fit into heterosexual or binary categories and supported the idea that a “third sex” (or Geschlecht ) existed naturally. Hirschfeld proposed the term “sexual intermediaries” for nonconforming individuals. Included under this umbrella were what he considered “situational” and “constitutional” homosexuals—a recognition that there is often a spectrum of bisexual practice—as well as what he termed “transvestites.” This group included those who wished to wear the clothes of the opposite sex and those who “from the point of view of their character” should be considered as the opposite sex. One soldier with whom Hirschfeld had worked described wearing women’s clothing as the chance “to be a human being at least for a moment.” He likewise recognized that these people could be either homosexual or heterosexual, something that is frequently misunderstood about transgender people today.

Magnus Hirschfeld, director of the Institute for Sexual Research, in an undated portrait. Credit: Magnus-Hirschfeld-Gesellschaft e.V., Berlin

Perhaps even more surprising was Hirschfeld’s inclusion of those with no fixed gender, akin to today’s concept of gender-fluid or nonbinary identity (he counted French novelist George Sand among them). Most important for Hirschfeld, these people were acting “in accordance with their nature,” not against it.

If this seems like extremely forward thinking for the time, it was. It was possibly even more forward than our own thinking, 100 years later. Current anti-trans sentiments center on the idea that being transgender is both new and unnatural. In the wake of a U.K. court decision in 2020 limiting trans rights, an editorial in the Economist argued that other countries should follow suit , and an editorial in the Observer praised the court for resisting a “disturbing trend” of children receiving gender-affirming health care as part of a transition.

Related: The Disturbing History of Research into Transgender Identity

But history bears witness to the plurality of gender and sexuality. Hirschfeld considered Socrates, Michelangelo and Shakespeare to be sexual intermediaries; he considered himself and his partner Karl Giese to be the same. Hirschfeld’s own predecessor in sexology, Richard von Krafft-Ebing, had claimed in the 19th century that homosexuality was natural sexual variation and congenital.

Hirschfeld’s study of sexual intermediaries was no trend or fad; instead it was a recognition that people may be born with a nature contrary to their assigned gender. And in cases where the desire to live as the opposite sex was strong, he thought science ought to provide a means of transition. He purchased a Berlin villa in early 1919 and opened the Institut für Sexualwissenschaft (the Institute for Sexual Research) on July 6. By 1930 it would perform the first modern gender-affirmation surgeries in the world.

A Place of Safety

A corner building with wings to either side, the institute was an architectural gem that blurred the line between professional and intimate living spaces. A journalist reported it could not be a scientific institute, because it was furnished, plush and “full of life everywhere.” Its stated purpose was to be a place of “research, teaching, healing, and refuge” that could “free the individual from physical ailments, psychological afflictions, and social deprivation.” Hirschfeld’s institute would also be a place of education. While in medical school, he had experienced the trauma of watching as a gay man was paraded naked before the class, to be verbally abused as a degenerate.

Hirschfeld would instead provide sex education and health clinics, advice on contraception, and research on gender and sexuality, both anthropological and psychological. He worked tirelessly to try to overturn Paragraph 175. Unable to do so, he got legally accepted “transvestite” identity cards for his patients, intended to prevent them from being arrested for openly dressing and living as the opposite sex. The grounds also included room for offices given over to feminist activists, as well as a printing house for sex reform journals meant to dispel myths about sexuality. “Love,” Hirschfeld said, “is as varied as people are.”

The institute would ultimately house an immense library on sexuality, gathered over many years and including rare books and diagrams and protocols for male-to-female (MTF) surgical transition. In addition to psychiatrists for therapy, he had hired Ludwig Levy-Lenz, a gynecologist. Together, with surgeon Erwin Gohrbandt, they performed male-to-female surgery called Genitalumwandlung —literally, “transformation of genitals.” This occurred in stages: castration, penectomy and vaginoplasty. (The institute treated only trans women at this time; female-to-male phalloplasty would not be practiced until the late 1940s.) Patients would also be prescribed hormone therapy, allowing them to grow natural breasts and softer features.

Their groundbreaking studies, meticulously documented, drew international attention. Legal rights and recognition did not immediately follow, however. After surgery, some trans women had difficulty getting work to support themselves, and as a result, five were employed at the institute itself. In this way, Hirschfeld sought to provide a safe space for those whose altered bodies differed from the gender they were assigned at birth—including, at times, protection from the law.

1926 portrait of Lili Elbe, one of Hirschfeld's patients. Elbe's story inspired the 2015 film The Danish Girl . Credit: https://wellcomeimages.org/indexplus/image/L0031864.html (CC BY 4.0)

Lives Worth Living

That such an institute existed as early as 1919, recognizing the plurality of gender identity and offering support, comes as a surprise to many. It should have been the bedrock on which to build a bolder future. But as the institute celebrated its first decade, the Nazi party was already on the rise. By 1932 it was the largest political party in Germany, growing its numbers through a nationalism that targeted the immigrant, the disabled and the “genetically unfit.” Weakened by economic crisis and without a majority, the Weimar Republic collapsed.

Adolf Hitler was named chancellor on January 30, 1933, and enacted policies to rid Germany of Lebensunwertes Leben , or “lives unworthy of living.” What began as a sterilization program ultimately led to the extermination of millions of Jews, Roma, Soviet and Polish citizens—and homosexuals and transgender people.

When the Nazis came for the institute on May 6, 1933, Hirschfeld was out of the country. Giese fled with what little he could. Troops swarmed the building, carrying off a bronze bust of Hirschfeld and all his precious books, which they piled in the street. Soon a towerlike bonfire engulfed more than 20,000 books, some of them rare copies that had helped provide a historiography for nonconforming people.

The carnage flickered over German newsreels. It was among the first and largest of the Nazi book burnings. Nazi youth, students and soldiers participated in the destruction, while voiceovers of the footage declared that the German state had committed “the intellectual garbage of the past” to the flames. The collection was irreplaceable.

Levy-Lenz, who like Hirschfeld was Jewish, fled Germany. But in a dark twist, his collaborator Gohrbandt, with whom he had performed supportive operations, joined the Luftwaffe as chief medical adviser and later contributed to grim experiments in the Dachau concentration camp. Hirschfeld’s likeness would be reproduced on Nazi propaganda as the worst kind of offender (both Jewish and homosexual) to the perfect heteronormative Aryan race.

In the immediate aftermath of the Nazi raid, Giese joined Hirschfeld and his protégé Li Shiu Tong, a medical student, in Paris. The three would continue living together as partners and colleagues with hopes of rebuilding the institute, until the growing threat of Nazi occupation in Paris required them to flee to Nice. Hirschfeld died of a sudden stroke in 1935 while still on the run. Giese died by suicide in 1938. Tong abandoned his hopes of opening an institute in Hong Kong for a life of obscurity abroad.

Over time their stories have resurfaced in popular culture. In 2015, for instance, the institute was a major plot point in the second season of the television show Transparent , and one of Hirschfeld’s patients, Lili Elbe, was the protagonist of the film The Danish Girl . Notably, the doctor’s name never appears in the novel that inspired the movie, and despite these few exceptions the history of Hirschfeld’s clinic has been effectively erased. So effectively, in fact, that although the Nazi newsreels still exist, and the pictures of the burning library are often reproduced, few know they feature the world’s first trans clinic. Even that iconic image has been decontextualized, a nameless tragedy.

The Nazi ideal had been based on white, cishet (that is, cisgender and heterosexual) masculinity masquerading as genetic superiority. Any who strayed were considered as depraved, immoral, and worthy of total eradication. What began as a project of “protecting” German youth and raising healthy families had become, under Hitler, a mechanism for genocide.

One of the first and largest Nazi book burnings destroyed the library at the Institute for Sexual Research. Credit: Ullstein Bild and Getty Images

A Note for the Future

The future doesn’t always guarantee progress, even as time moves forward, and the story of the Institute for Sexual Research sounds a warning for our present moment. Current legislation and indeed calls even to separate trans children from supportive parents bear a striking resemblance to those terrible campaigns against so-labeled aberrant lives.

Studies have shown that supportive hormone therapy, accessed at an early age, lowers rates of suicide among trans youth. But there are those who reject the evidence that trans identity is something you can be “born with.” Evolutionary biologist Richard Dawkins was recently stripped of his “humanist of the year” award for comments comparing trans people to Rachel Dolezal , a civil rights activist who posed as a Black woman, as though gender transition were a kind of duplicity. His comments come on the heels of legislation in Florida aiming to ban trans athletes from participating in sports and an Arkansas bill denying trans children and teens supportive care.

Looking back on the story of Hirschfeld’s institute—his protocols not only for surgery but for a trans-supportive community of care, for mental and physical healing, and for social change—it’s hard not to imagine a history that might have been. What future might have been built from a platform where “sexual intermediaries” were indeed thought of in “more just terms”? Still, these pioneers and their heroic sacrifices help to deepen a sense of pride—and of legacy—for LGBTQ+ communities worldwide. As we confront oppressive legislation today, may we find hope in the history of the institute and a cautionary tale in the Nazis who were bent on erasing it.

Brandy Schillace is editor in chief of BMJ's Medical Humanities journal and author of the recently released book Mr. Humble and Doctor Butcher , a biography of Robert White, who aimed to transplant the human soul.

He made this town the world’s ‘sex-change capital,’ but he’s not honored here

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If you’re looking for evidence that this little-known Western outpost was, for 41 years, known as the world’s “sex-change capital,” be prepared to look a long time.

Dr. Stanley Biber, the colorful country surgeon whose pioneering work made “going to Trinidad” a euphemism for gender confirmation surgery, has been dead since 2006 . His decades of work, which brought medical pilgrims from around the world to this heavily Catholic former coal-mining town, is not commemorated in any way at Mt. San Rafael Hospital, where Biber and his protege, Dr. Marci Bowers, performed an estimated 6,000 gender surgeries between 1969 and 2010.

For the record:

11:15 a.m. Sept. 12, 2019 A photo caption on an earlier version of this article misidentified Trinidad, Colo., Councilman Joe Bonato as Joe Binato.

Biber’s widow removed a display of her late husband’s medical artifacts from the hospital’s lobby when she moved to Pueblo after his death and says her discussions with the city about naming a nearby street after Biber went nowhere.

You’ll find no statue, memorial, or even a plaque marking Biber’s long career as the man who brought Trinidad world renown, though many other significant chapters in local history are acknowledged by plaques along downtown sidewalks. It wasn’t until May, more than 13 years after the surgeon’s death, that the local museum included any mention of his work in an exhibit space that celebrates practically every other detail of the city’s remarkable Old West history.

Until then, the only evidence that Biber even existed were the personal stories shared by many in town whose lives he touched, his unremarkable gravestone in the Jewish section of Trinidad’s Masonic Cemetery and the outdated directory of tenants painted on the gray marble wall of a side entrance to Main Street’s First National Bank building, where for decades a creaky elevator carried patients up to his musty private office for pre-surgery consultations. The building’s hand-lettered mention of “Dr. S.H. Biber, P.C., Surgeon” among the fourth-floor tenants remains today simply because no one has bothered to remove it.

But at this pivot point in American history, when many still struggle to reconcile a binary view of gender with the proven complexities of a gender spectrum, and hard-fought rights advances for transgender Americans are being rolled back, the story of Stanley Biber and his pioneering work in Trinidad offers a remarkable tale of insight and compassion. Why did a doctor in a Western frontier town embrace transgender men and women decades ahead of most, and dedicate a good deal of his professional life to easing their pain? And why does he remain such an unknown figure?

Some say the story began during Biber’s service as a battlefield surgeon in the Mobile Army Surgical Hospital during the Korean War.

Korea is where Biber thrived on the challenge of innovating as his patients’ conditions changed, and he developed a reputation for tirelessness by performing 37 consecutive surgeries before passing out from exhaustion. He honed his surgical dexterity trying to save soldiers whose lower bodies were devastated by wounds to reproductive organs, bowels and urinary tracts.

World & Nation

How Stanley Biber, a pioneer in gender confirmation surgery, won over the Sisters of Charity

When he started the gender-confirmation surgeries in Trinidad, Colo., Dr. Stanley Biber had some explaining to do — to the nuns who worked as patient advocates.

Sept. 12, 2019

While Biber excelled at a number of things during his postwar life — he claimed to have missed the U.S. Olympic weightlifting team “by 20 pounds,” and even into his 80s would roll up his sleeves over his biceps to show off his guns — he seized the chance to become a small-town doctor. In 1954, he joined the staff of a clinic the United Mine Workers opened in Trinidad, where about half of Las Animas County’s 26,000 residents lived. At that point, Biber was the only general surgeon in town.

“He was so dedicated there,” says Ella Mae Biber, the fourth of his five wives and to whom he was married for 23 years. “He delivered so many babies, did everybody’s surgery, and everybody trusted him tremendously. He loved everyone in Trinidad. You don’t see doctors commit to their patients anymore. He took care of them from birth to death, in most cases.”

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It’s hard to find a local today who’s not eager to share a personal story of the time Biber set a broken bone, did an unexpected minor surgery during an office visit, or delivered them squalling into the world. Trinidad resident Dick Hamman credits Biber with saving his father’s life when he developed peritonitis after an appendix rupture: “You put a scalpel in his hand and he was Michelangelo.”

The moment that would change Biber’s life, the reputation of his adopted hometown and the lives of thousands of transgender patients “came to him by accident,” his stepdaughter Kelly Biber recalls. “It just kind of walked into his office one day.”

His visitor was a social worker with whom Biber had often consulted. As Biber recounted in various interviews, the red-haired woman lingered a moment after their meeting ended. Eventually, she asked a question: “Can you do my surgery?”

The ever-confident Biber agreed without discussion, boasting, “Of course I can do your surgery. What do you want done?”

His visitor explained that she was a “transsexual woman.” Biber pondered her words before finally asking: “What’s that?”

It was 1969. Sure, he knew about the Christine Jorgensen case, in which a former Army clerk had gender confirmation surgery in 1952. Who didn’t? But at the time, the term “transsexual” was hardly part of the cultural vocabulary.

You put a scalpel in his hand and he was Michelangelo.

— TRINIDAD RESIDENT DICK HAMMAN

At the time Johns Hopkins Hospital in Baltimore was an American center of what then was called “sex-change surgery.” Biber called a plastic surgeon there who had done about 13 such operations, seven of which were what Biber described as “simple penectomies” similar to the operation done on Jorgensen. That surgeon eventually sent Biber a set of rudimentary hand-drawn diagrams showing the basic technique for deconstructing genitalia and reconstructing it into a vagina. Biber looked over the drawings and called the social worker back. “Well, I’ve never done one, but if you want to do it, I think we can do it.”

In the late 1960s, transgender men and women seeking surgical relief didn’t have many options, but many were emboldened by an evolving culture. Susan Stryker, author of the 2008 book “Transgender History,” describes the dawning of a “transgender aesthetic” back then — gender-bending entertainers such as rock artists the New York Dolls and David Bowie were finding their way into the American mainstream — that signaled a changing relationship between appearance and assigned sex. It was the start of a cultural conversation about how gender might be more complicated than a simple binary choice: male or female?

But back when many of the better-known university clinics were following the lead of influential Johns Hopkins, which decided to drop its program in 1979, Biber’s fledgling specialty practice in Trinidad was a revelation to many transgender men and women. Here was a skilled surgeon at a real hospital who offered them help, dignity and hope — all with a dose of unflappable confidence, and without judgment. That combination was enough to coax people to Trinidad from thousands of miles away.

During his peak years, Biber was doing up to four gender confirmation surgeries a week, for both male-to-female and female-to-male patients.

His work made headlines — and occasionally drew the attention of self-righteous outsiders. In 1999, for example, members of the staunchly anti-LGBTQ Kansas-based Westboro Baptist Church arrived to picket what its news release for the event described as “Satan’s physician” and the town it called the “anteroom to Hell.” Feature stories about Biber appeared in this newspaper and other national media, and TV show host Geraldo Rivera and his camera crew documented a surgery.

As far as his grandkids are concerned, Biber’s fame peaked with a 2005 episode of the animated TV series “South Park” called “Mr. Garrison’s Fancy New Vagina,” in which the show’s transgender schoolteacher character travels to see Dr. Biber at the Trinidad Medical Center to undergo surgery. (Biber was not pleased, his stepdaughter Kelly recalls.)

Trinidad as the world’s “sex-change capital” didn’t register much in the mainstream American consciousness during those years, and was easy to dismiss as a distant signal emanating from the middle of nowhere. Transgender men and women were unfamiliar to many, and hard to fathom. But day in and day out, week after week, month after month, year after year, the pilgrims came to Trinidad.

They continued to do so until Biber’s age and inability to get liability insurance caught up with him in 2003. He died three years later after training Bowers, a transgender surgeon from Seattle he hoped would carry on his practice in Trinidad. But where Biber was low-key, humble and a longtime member of the community who once served on the county commission, Bowers’ silver Porsche Boxster and more active courtship of publicity — she starred in a short-lived BBC reality TV series called “Sex Change Hospital” — didn’t sit well with the locals and hospital officials. She left town in 2010, moving her practice to Burlingame, Calif., and bringing that peculiar chapter in the city’s history to a close.

The local invisibility of the man behind such a vital chapter in transgender history may be less a result of social taboo, discrimination and local politics than Trinidad’s own identity struggle over the years.

Founded in 1862 after rich coal seams were discovered in the region, Trinidad was a company town by 1910. Colorado Fuel and Iron operated the largest steel mills in the West, as well as dozens of mines, coke ovens, transportation lines and other infrastructure needed to support the local industry. CF&I created countless small communities for the mine workers it recruited from throughout Europe, believing that people who spoke different languages were less likely to organize into unions to improve the often brutal working conditions.

Those conditions led to a notorious chapter in labor history just a few miles north of Trinidad. Union leader Louis Tikas, 12 children and two women were among 20 who died in a violent company crackdown known as the Ludlow Massacre in spring 1914 — a conflict that former Colorado state historian William J. Convery has called “the bloodiest civil insurrection in American history since the Civil War.”

Trinidad transformed itself after the coal industry began to fade in the 1920s, achieving a strange sort of prosperity, or at least notoriety, during Prohibition when Chicago mobster Al Capone and his family hid out in Trinidad and nearby Aguilar by blending in with the Italian immigrant families who continued to call the city home.

Those various bursts of 20th century prosperity left Trinidad with lavish hotels, a Carnegie Library, an opera house, churches and the oldest continuously active synagogue in the state. A 2012 promotional film produced in part by the county Chamber of Commerce referred to Trinidad as “the Victorian jewel of southern Colorado” without ever mentioning the medical claim to fame for which today it remains best known.

Lately, Trinidad, nicknamed “Weed Town, USA” by High Times magazine, has become a center of legal marijuana cultivation and sale. Thanks to its proximity to several states where recreational marijuana remains illegal, it has attracted thousands of pot tourists, and the town of fewer than 10,000 residents now boasts more than 30 such enterprises. The revenue is helping with long overdue upgrades to Trinidad’s infrastructure, but the weed boom may not last forever, especially if neighboring New Mexico legalizes in the coming years.

City leaders already are looking beyond the current green rush. They envision a community as a center for arts and recreation. The city and two conservation groups just announced a $25-million plan to buy Fisher’s Peak, the iconic stair-stepped mesa that overlooks the city, as well as the 30-plus square miles of wilderness around it. They plan to build a hiking trail from the center of town up to the peak, and the state announced plans this week to turn it into a state park.

During my spring 2018 visit to research a book about Biber’s career in Trinidad, the surgeon’s legacy was entirely invisible. But 15 months later, there was talk of plans to celebrate him, a local 1960s-era commune called Drop City and other creative renegades in a new counterculture museum, which would be part of the new state-orchestrated creative district taking shape in the heart of downtown. It’s still in the planning stages, but the possibility suggests a growing acknowledgment that Biber has perhaps been overlooked.

The most telling sign that the city is getting more comfortable with Biber’s place in local history is the oblique line in the new Trinidad Visitor’s Guide. Without mentioning Biber by name, it reads: “For half a century, Trinidad welcomed thousands of individuals seeking to become who they were born to be.” It touts that as evidence that Trinidad is “one of the most welcoming places in the country.”

Trinidad native Jay Cimino, chief executive of the Phil Long chain of car dealerships and a benefactor behind a number of town initiatives, also foresees a spot for Biber in the gallery of Trinidad’s “champions” he’s assembling in the entry hall of the refurbished Champions Building on Commercial Street, not far from Biber’s old office. That gallery celebrates not just local sports and education heroes, but also those who “championed” people who needed help. Those include Sister Blandina Segale of the Sisters of Charity religious order who helped establish Colorado’s first school district in Trinidad and whose kindness is said to have helped persuade Billy the Kid to change his outlaw ways.

“It certainly would not surprise me if Biber’s name came up as a champion in this town,” Cimino says. “It should.”

You may have concluded that Biber’s obscurity suggests a certain discomfort among locals with his chosen area of specialty, or a continuing marginalization of that important history for transgender Americans. Most locals will tell you that you’re wrong, including one you might expect to take Biber’s exclusion as a personal slight.

Trinidad City Councilwoman Michelle Miles came to Trinidad for gender confirmation surgery in 2005 and later made it her home — one of the few medical pilgrims to have done so. She says Trinidad is just not the kind of place that goes around putting up statues and plaques.

“The only commemorations I see are Coal Miners Memorial Park and the Coal Miners Museum, because that’s such a rich part of Trinidad’s tradition,” says Miles, a former Wall Street investment banker. “So are Billy the Kid, Bat Masterson, Doc Holliday and Kit Carson. Good lord, it’s an incredible history.”

Like so much of the West, Miles says, her adopted hometown is “driven by people looking for an opportunity to re-identify themselves, and reinvent themselves.” Even today, she adds, identity politics don’t matter much in Trinidad. “I don’t run on trans issues when I run for City Council. I just live my life. People casually know that I’m trans, and it’s OK, and that’s just the way it is.”

Paula Manini, former director of the Trinidad History Museum, voiced the same sentiment to NPR in a piece that aired shortly after Biber’s death: “You know that Western attitude … what you do is your business, what I do is mine, and that’s it.”

Dawn DiPrince, chief operating officer of History Colorado, the state historical society, was the lead developer of the “Borderlands” exhibit that opened in May at the Trinidad History Museum. It focuses on how land management and healthcare changed in that frontier region after the Treaty of Guadalupe Hidalgo moved the Mexican border farther south and made southern Colorado part of the United States. The exhibit includes a small tribute to Biber — apparently the first of its kind in town — that includes the old camera the surgeon used to take pre-surgery photographs of his transgender patients. During a recent visit, museum director Kirby Stokes proudly showed off the Biber display.

“When you operate in a borderland, you’re on the margins, not close to the centers of power,” DiPrince says. “If you exist on the margins, there’s a lot of opportunity for invention and creativity, and for taking risks that people would not ordinarily do if they were more in the mainstream.”

DiPrince says Biber was a perfect example of that, and suggests that remote Trinidad may have been one of the few places where his transgender work could flourish the way it did.

Miles says a more elaborate Biber tribute may someday follow, but notes that the town only recently erected a statue honoring Greek immigrant and labor hero Louis Tikas, the first victim in the Ludlow Massacre, and only then because his family and the Denver chapter of the Foundation of Hellenism of America commissioned it. Miles says Trinidad’s only involvement was to have city workers build a pedestal along Main Street.

That public commemoration of Tikas took 104 years.

Former Los Angeles Times Magazine senior editor Martin J. Smith has just completed a nonfiction book titled “Post-Op: Untold Stories of Life, Love, and Transformation from the World’s Unlikely ‘Sex-Change Capital.’ ”

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Remembering Dora Richter, One of the First Women to Receive Gender-Affirming Surgery

To celebrate Women’s History Month, we’re telling the stories of transgender women who reshaped history. Below, we recount the life of Dora Richter, one of the first people to receive gender confirmation surgery, and whose life was cut brutally short during the Nazi uprising.

When people discuss milestone moments in transgender history, they often point to the first known sexual “reassignment” surgeries. Some will talk about Christine Jorgensen , who became the first trans celebrity in the West to receive a vaginoplasty in the 1950s, or dive earlier back to discuss Lili Elbe’s fatal womb transplant in 1932. (The latter was the subject of the now-infamous, heavily falsified drama The Danish Girl , starring Eddie Redmayne).

But in reality, neither of these famous names were truly the first to receive gender-affirming surgery. That distinction likely belongs to another woman, whose name might have been lost to time if her murderers had their wish. And the reason she’s not a household name is the same reason trans people are still under attack by the far right today.

Dora Richter was born in 1891 on a farm somewhere in the Ore Mountains, or Erzgebirge, on the border of what’s now Germany and the Czech Republic. Little is known about her childhood except that her dysphoria seems to have been intense and began early; she was so insistent on her femininity that her parents allowed her to live as a girl and, according to surviving medical records, she attempted to remove her penis with a tourniquet at least once when she was six.

Upon reaching adulthood, Richter — who by then had begun going by the name Dӧrchen, or “Dora” for short — left her rural home and traveled more than 200 kilometers north to Berlin, where she took up seasonal work as a “male” waiter in various upper-class hotels, living as herself in the off-season. This double life was not without peril, however, even in the permissive Weimar Republic era ; Dora was repeatedly arrested for wearing dresses in public and made to serve her time in male prisons.

Finally, after one such arrest around 1920, a more understanding judge released Richter into the care of Dr. Magnus Hirschfeld, who promised her employment at his Institut fur Sexualwissenchaft , or Insitute for Sexual Science — the first modern research institute for queer and transgender health, nestled in Berlin’s idyllic Tiergarten park. Hirschfeld, himself a gay Jewish man, had in the previous two decades established himself as one of the leading researchers of gay and transgender identities, pioneering research alongside surgeons and psychologists like Eugen Steinach and Arthur Kronfeld, many of whom came to work as residents or visiting fellows after the Institute’s founding.

At the Institute, Dora — now granted an official pass to present as a woman in public — worked as a housemaid while the medical team assessed her needs, the most immediate being an orchiectomy, which she obtained via a surgeon named Dr. Erwin Gohrbandt in 1922. Steinach’s work during the 1910s on testicles and testosterone , which helped identify how hormones influence sexuality and the human body (and to which Hirschfeld referred some of his own patients), helped Hirschfeld build on his theories about how a lack of testosterone might alter a “male” body’s fat distribution; Dora’s surgery provided a chance to study the effects. Sure enough, as the Institute’s forensic sexologist Felix Abraham later wrote, in the years after her first surgery, Dora’s “body became fuller, the growth of beard diminished, breast growth became noticeable and also the fat pad of the pelvis... took on more feminine forms.”

Over the next decade, Hirschfeld’s surgical team refined their theories and techniques, while Dora established herself as part of the team of trans women who made up the essential housekeeping staff; they included women like painter Toni Ebel and her longtime lover Charlotte Charlaque, who worked as the Institute’s receptionist. Together, they were human test subjects for the first trial runs of modern vaginoplasty surgery, brave and desperate enough to give their bodies to science for a chance at a new life. By the dawn of the 1930s, the women’s patience bore fruit, and the first full reassignment surgeries began. Although the timeline remains unclear on when each procedure took place, it’s believed that Dora received one of the Institute’s first full reassignments in 1931, when she was 40 years old.

The penile inversion technique used today was still decades away from being developed, and Dora’s surgery was a rudimentary two-part affair: a penectomy performer by Dr. Levy-Lenz, followed by the construction of a neovagina by Dr. Gohrbandt. Still, Richter’s vaginoplasty and those of her friends and fellow workers at the Institute were an extraordinary success, and attracted other European trans women to Berlin, including Lili Elbe.

1931 was also the year that Magnus Hirschfeld left the Institute on a lecture tour of Asia and North America, never to return to Germany. In the decade Dora had waited for her new life to begin, the Nazi cancer had metastasized within the Weimar Republic, and Hitler’s official rise to power in the 1932 Reichstag elections marked the Institute’s death knell; Hirschfeld himself had been labeled “the most dangerous Jew in Germany” by the new führer and attacked several times on the street. The work of a gay Socialist Jew could never be suffered to survive — much less the degenerates he enabled.

On May 6, 1933 , Nazi storm troopers and gangs of nationalist students descended on the Tiergarten and laid waste to the Institute, dragging the building’s inhabitants into the street to be shot and destroying the books and files within. (Toni and Charlotte escaped to Czechoslovakia, but that’s another story.) It’s not clear precisely what happened to Dora — whether she was murdered on the spot, or sent to a camp and killed later. Perhaps, a few days later, she bore witness to Joseph Goebbels’ speech as the fascists set ablaze more of the Institute’s research along with heaps of Jewish and Communist literature. Whatever the truth, all historical traces of Dora’s life end with the Institute’s death.

The assault on the Institute was a twofold slaughter — the Nazis killed not only the people who called it home, but the physical evidence that showed that they’d lived, and how; notes from Abraham’s lectures and the case files of Levy-Lenz, photos of Dora and her surgeries and her smile, anything that could have been valuable to the next queer generation — any proof that there’d been a place for trans women to live and heal in peace — was snuffed out. After all, the goal was to make sure this was the last queer generation.

Naturally, there are still queer and trans people, because we have always existed throughout history and always will. Hirschfeld and several of his contemporaries lived on in exile, passing on their knowledge as best they could. Their insights eventually led to other breakthroughs in trans surgical science, like Harry Benjamin’s pioneering surgical procedures in the U.S. in the ‘40s, ‘50s and ‘60s. But these small blessings are shadows of what might have been if not for the right-wing violence that killed so many people and hid their stories from the world for decades.

Unlike Lili Elbe, whose diary survived her, little firsthand information remains of Dora beyond what her doctors wrote about her in medical journals. A 1999 German dramedy about Hirschfeld’s life, The Einstein of Sex, heavily edits details of Richter’s life for the sake of plot convenience; there are no blockbusters bearing her name. Through decades of work of LGBTQ+ historians, we can presume to understand the arc of her life, but we don’t know Dora, because a few people didn’t want her to live and tell her story. They found Dora, and everyone like her, monstrous, her joy a blight, and her desires poisonous to the general public.

That base hatred, and its bigoted conception of trans people writ large, is what drives anti-trans attacks today — from Greg Abbott’s witch hunt against parents of trans kids in Texas to LGBTQ+ book bans and Marjorie Taylor Green saying that trans people must be “ beat[en] into the ground ” on InfoWars . It’s familiar rhetoric, one that echoed on the streets of Berlin a century ago; today, we are all the most dangerous transsexuals in America.

After receiving surgery that helped relieve the intense dysphoria she’d faced since childhood, Dora Richter was cut down just as her life was beginning to blossom. In essence, that’s what right-wing ideologues and politicians want when they criminalize hormone therapy and surgeries: the end of trans people in public life. More than a hundred years after Dora first walked through the threshold of what would be her final home, trans people in the U.S. and around the world are facing down another wave of fascist violence from people who think if they crush enough trans people, they can kill the whole idea of being trans forever.

But in the end, nobody could truly kill the memory of little Dӧrchen, the mountain girl whose dream of a better life helped those of so many others come true. So what hope do they have against all of us?

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• Introduction

Gender-affirmation care

Development, advances in gender-affirming care.

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gender-affirming surgery

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• Table Of Contents

gender-affirming surgery , medical procedure in which the physical sex characteristics of an individual are modified. Gender-affirming surgery typically is undertaken when an individual chooses to align their physical appearance with their gender identity , enabling the individual to achieve a greater sense of self and helping to reduce psychological distress that may be associated with gender dysphoria .

An individual’s physical sex may not match their gender identity when the person is intersex , having been born outside the binary of male and female and thus having ambiguous genitalia, or when the person identifies as transgender . Parents of an intersex child may elect to have surgical procedures carried out in order to have the child’s anatomy conform to binary notions of gender . A person’s ascribed legal sex may not match their gender identity as they mature. However, this situation raises serious concerns regarding the appropriateness of performing unnecessary medical procedures on the bodies of minors. Intersexuality is a normal biological variation and is not considered a medical condition. Therefore, medical interventions such as surgery and hormone therapy are typically unnecessary for intersex children.

Transgender individuals may seek gender-affirming surgery to align their physical body with their perception of their gender identity. Gender identity refers to an individual’s perception of their own gender, which may or may not correspond to their designated gender at birth. Gender identity encompasses the identification as male, female, both, neither, or somewhere else on the spectrum of gender. It is distinct from biological sex, which is determined by the sex chromosomes and anatomy of an individual. While the gender identity of most individuals corresponds to their ascribed biological sex, the gender identity of some individuals differs from their ascribed sex at birth, which can result in gender dysphoria and thereby lead the individual to seek gender-affirming surgery.

Individuals assigned male at birth may undergo one or more procedures to feminize their anatomy, including facial feminization surgery, penectomy (removal of the penis ), orchidectomy (removal of the testicles ), vaginoplasty (construction of a vagina ), and a tracheal shave (reduction of the Adam’s apple). Individuals who are assigned female at birth and who desire surgical intervention to masculinize their anatomy may seek breast reduction surgery, hysterectomy (removal of the uterus ), oophorectomy (removal of the ovaries ), and phalloplasty (construction of a penis).

Gender-affirming surgeries were performed during the 1920s and ’30s, primarily in Europe. These procedures were experimental and not extensively accepted by the medical community . At the time, it was widely believed that gender identity was immutable and that surgery could not alter it. However, Magnus Hirschfeld , a German sexologist and vocal advocate for sexual and gender diversity , assisted with the care of several transgender individuals.

Dora Richter was the first transgender individual to undergo complete male-to-female genital surgery under Hirschfeld’s supervision. Richter was one of several transgender individuals under Hirschfeld’s care at the Berlin Institute for Sexual Research. In 1922 Richter underwent an orchidectomy and, in 1931, a penectomy and vaginoplasty.

In 1930 and 1931 Lili Elbe also underwent several gender-affirming surgeries. These procedures included an orchidectomy, an ovarian transplant, and a penectomy. Elbe underwent a fourth surgery in June 1931, which consisted of an experimental uterine transplant and vaginoplasty. Elbe’s body rejected the transplanted uterus, and she died of postoperative complications in 1931.

During the 1950s and ’60s, significant advancements were made in the field of gender-affirming surgery, including the establishment of several major medical centres and the refinement of surgical techniques. Christian Hamburger, a Danish endocrinologist, performed a gender-affirming surgery in 1952 on Christine Jorgensen , a transgender individual, who underwent hormone replacement therapy and surgery to remove her testicles and create a vagina. Jorgensen became a public figure advocating for transgender rights and promoting awareness about gender-affirming surgery after their case received significant media attention.

Other medical centres in Europe and the United States began conducting gender-affirming surgeries around the same time, including the Johns Hopkins Gender Identity Clinic, founded in 1966. The founder of the clinic, psychiatrist John Money, believed that gender was a social construct and that gender-affirming surgery could be an effective treatment for individuals with gender dysphoria. Money’s theories had a significant impact on the field of gender-affirming surgery and helped to change the attitudes of the medical community regarding the procedure.

During the 1960s, new surgical techniques were developed, including advances in vaginoplasty and phalloplasty. In the 1950s Belgian surgeon Georges Burou devised a technique involving the use of skin grafts from the patient’s thigh to create a vaginal canal lining. For penises, he attached the phallus to a blood supply using tissue . This technique improved tissue perfusion and decreased the risk of complications such as tissue necrosis . These procedures marked a turning point in the development of gender-affirming care because they demonstrated the potential for successful genital reconstruction in transgender patients.

Brief History of Gender Affirmation Medicine and Surgery

• First Online: 20 January 2021

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• Prashant Upadhyaya 3  

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Gender dysphoria is the inner conflict and distress caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth. The earliest reports of gender identity alteration can be traced back to 1500 BC in ancient Egypt and during the Roman Empire (509 to 27 BC). During the modern era, Magnus Hirschfeld was considered the father of transgender healthcare and established the Institute for Sexual Science in Berlin. This was the world’s first institute devoted to sexology and was the site of the first documented gender affirmation surgery: orchiectomy, penectomy, and vaginoplasty in a transgender female patient. Dr. Harry Benjamin was a close friend of Hirschfeld who also had a keen interest in transgender healthcare and advocacy. Dr. Benjamin assisted hundreds of transgender individuals by prescribing hormones and suggested they visit surgeons abroad for gender affirmation surgeries. He later founded the Harry Benjamin International Gender Dysphoria Association (HBIGDA), which outlined standards of care for transgender individuals who desired medical and surgical treatment. In 2007, HBIGDA became known as the World Professional Association for Transgender Health (WPATH), which is a professional organization dedicated to the care and treatment of individuals with gender dysphoria today.

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Bhinder, J., Upadhyaya, P. (2021). Brief History of Gender Affirmation Medicine and Surgery. In: Nikolavsky, D., Blakely, S.A. (eds) Urological Care for the Transgender Patient. Springer, Cham. https://doi.org/10.1007/978-3-030-18533-6_19

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

By Theresa Gaffney Oct. 3, 2022

N early 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.

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“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.

Related: Harassment prompts children’s hospitals to strip websites, threatening access to gender-affirming care

“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.

Related: Gender-affirming care should be embraced, not met with vitriol and bomb threats

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.

Related: ‘Critically important work’: Adm. Rachel Levine on efforts to combat gender-based discrimination in health care

“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.

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Genital gender-affirming surgery: a history from the shadows to the forefront.

Gender dysphoria is characterized by a discrepancy between an individual’s gender at birth and the gender with which they identify themselves. Gender-affirming surgery encompasses a variety of procedures that aim to alleviate gender dysphoria. These are broadly divided into “top surgery” or “bottom surgery” for both birth-assigned females being affirmed as males (FTM) as well as birth-assigned males being affirmed as females (MTF). Bottom surgery refers to a number of inter-related procedures with a goal of genital reconstruction in transgender patients. In FTM patients, this focuses on phalloplasty, or the creation of a penis. In MTF patients, bottom surgery largely signifies vaginoplasty, or the creation of a vagina. Genital reconstruction, along with gender-affirming surgery overall, has a unique and interesting history.

The first studies focusing on transgender individuals were published in the nineteenth century. In the United States, widespread attention on the transgender community was not received until 1953 when Christine Jorgensen, a World War II veteran, underwent gender-affirming surgery in Copenhagen. By 1966, Dr. Harry Benjamin published The Transsexual Phenomenon , which advocated for gender affirming surgery, rather than conversion therapy as was advocated by many who felt gender dysphoria represented a mental illness. During the 1960s, multiple centers throughout the country, with Johns Hopkins being the first, opened clinics for transgender individuals seeking gender-affirming surgery. The number of centers as well as private surgeons performing such procedures has since continued to rise.

Genital reconstruction for MTF patients, again largely representing the creation of a new vagina, has its roots in he nineteenth century as similar procedures at that time were described in female patients with congenital, traumatic, or surgical wounds of their vagina that required reconstruction. The first MTF patient to undergo documented vaginoplasty was Dorchen Richter in 1931. The first high profile case was the case of Christine Jorgensen in 1953, which was performed using a skin graft from the penis that had been removed during the same procedure. Prior to this, vaginal reconstruction was largely performed with skin grafts from the back, buttocks, or thigh. In the 1950s, the technique of penile inversion vaginoplasty was first described and performed. In this procedure, which has largely become the most common method in current practice, the penile skin is freed and inverted internally to create the new vagina. This technique may be supplemented as needed with additional skin grafts. A less common method of vaginoplasty involves using a piece of intestine to create the vagina.

Gender-affirming surgery for FTM patients involves the creation of a penis (phalloplasty) with ultimate goals of allowing for urination while standing as well as for sexual penetration. The first description of such procedures for gender affirming surgery is by Sir Harold Gilles in the 1940s in which he used tissue from the patient’s abdomen to perform the phalloplasty. These phalloplasty techniques using nearby tissue that stayed connected to either the abdomen or thighs remained popular through the 1970s. Notably, the first documented case of FTM phalloplasty in the United States was performed in the 1960s. During the 1980s, various other methods for phalloplasty were described, although initially they were performed largely for males with penile injuries. These included using distant tissue from the arms, legs, or back to create a new penis. Over the years, these procedures have been performed more commonly, although they remain plagued by various issues with many surgeons working to improve outcomes.

Overall, genital reconstruction for gender-affirming surgery is a challenging surgical field that aims to alleviate gender dysphoria in transgender individuals. Gender-affirming surgery possesses a unique historical perspective through which progress in today’s modern era can be viewed.

Jordan D. Frey, Alexes Hazen Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA

Publication

A Historical Review of Gender-Affirming Medicine: Focus on Genital Reconstruction Surgery. Frey JD, Poudrier G, Thomson JE, Hazen A J Sex Med. 2017 Aug

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From gi joe to gi jane: christine jorgensen’s story.

WWII veteran Christine Jorgensen became the first American transgender woman to attain fame for having sex reassignment surgery. Her story has influenced many others and helped redefine gender identity.

Top Image: Photo of Christine Jorgensen taken by Maurice Seymour in January 1954. Courtesy of Wikicommons.

One day while flipping through my dad's collection of vintage Life magazines, the headline “Ex-GI Becomes Blonde Beauty” caught my eye. What followed was the fascinating story of Christine Jorgensen. Jorgensen, who served in the US Army during and after World War II, became the first American transgender woman to attain fame for having sex reassignment surgery. The article celebrated her heroism during the war and embraced her feminine qualities, such as her hair and fashionable clothes. Interestingly, the article was published in 1952, a time when gay and lesbian WWII veterans were often stripped of their medals and fired from their jobs because of who they loved. But why was Jorgensen celebrated when other members of the LGBTQ (Lesbian, Gay, Bisexual, Transgender, and Queer) community were not?

Christine was born George William Jorgensen, Jr. on May 30, 1926 in the Bronx, New York City. As a child, Jorgensen felt very different from other little boys and remained secluded and shy. The boys poked fun at Jorgensen’s feminine tendencies and even her own sister would chime in now and then. She seemed to gravitate toward dolls and dreamed of having the elegant feminine qualities that a woman possessed. In one of Jorgensen’s early memories, she recalled questioning her identity to her mother: “‘Mom,' I asked, 'why didn’t God make us alike? My mother gently explained that the world needed both men and women and there was no way of knowing before a baby was born whether it would be a boy or girl.” Jorgensen’s family was very close, and her grandmother became Jorgensen’s biggest champion and supported Jorgensen expressing her identity. In high school, Jorgensen developed an attraction to her male friends, but she knew at the time, she was not gay. Instead, she realized that she was a woman trapped inside a man’s body.

 After Jorgensen graduated high school during World War II, she tried to enlist in the Army, but she was denied because of her dainty size and weight. However, a couple of months later she was drafted into the Army and stationed at Fort Dix, New Jersey. During Jorgensen’s service, she kept mostly to herself and concealed her attraction to men. At the time, many service members feared being exposed or labeled as a homosexual, which could get a soldier prison time, a dishonorable discharge, or court-martialed. Jorgensen explained that, “I wanted to be accepted by the army for two reasons. Foremost was my great desire to belong, to be needed, and to join the stream of activities around me. Second, I wanted my parents to be proud of me.” She labored as a clerical worker, managing thousands of discharged soldiers after VE Day for 14 months until she herself was honorably discharged in December 1946.

Jorgensen’s Army registration card courtesy of Fold3.com.

After Jorgensen’s military service, she went to photography school in New Haven, Connecticut, and dental assistant school in New York City. Jorgensen was still unhappy with her life, however, and she began to look for answers in books, hoping she might find answers. One book called The Male Hormone piqued her interest and helped explain her problems, which led her to start taking estrogen. Then, she consulted with doctors about surgeons in Europe who had already performed sex reassignment surgery. Jorgensen was determined to be transformed into a woman, and in 1950, she traveled to Denmark to pursue her dreams.

When Jorgensen arrived in Denmark, she met endocrinologist Dr. Christian Hamburger, who agreed to do the experimental procedure for free. He was the first person to diagnose Jorgensen as transsexual and not homosexual. For the next two years, Jorgensen underwent hormone treatment, psychiatric evaluations, and finally surgery to remove her male genitalia. Unfortunately, she did not receive a surgically created vagina until years later when she was back in the United States. Before she returned to the United States, she had one last alteration to make in order to complete her transformation. She changed her name to Christine in honor of Dr. Hamburger’s work of making her dreams come true.

Jorgensen's arrival in the United States from Denmark. Image courtesy of TransasCity.org.

 Telegram of Jorgensen's story. Image courtesy of TransasCity.org.

Upon Jorgensen’s arrival home, her story reached the newspapers and on December 1, 1952, she made the front page of the New York Daily News under the headline “Ex-GI Becomes Blonde Beauty: Operations Transform Bronx Youth.” In the following months, hundreds of newspapers featured her story, and she became an overnight sensation. The press and public’s reaction came as a great shock to Jorgensen: “I was surprised that everyone seemed very interested in my life… time went on and I realized this was an important step in the eyes of the world.”

Soon after she arrived, she was given a very prestigious award by the Scandinavian Societies of Greater New York, where she was made “Woman of the Year.” Image courtesy of TransasCity.org.

Headlines emphasized her GI background and embraced her as an American beauty by describing her long legs, blonde hair, and high fashion clothes. Jorgensen’s patriotism as a WWII veteran and beautiful feminine attributes embodied American values and structure, which captivated the public and press. Her transition from a man to a woman also showed the world the advancement of technology and medical science. These qualities help explain why the press and American society celebrated Jorgenson’s story. Although not everyone was so kind.

Like most members of the LGBTQ community, Jorgensen experienced her share of hate and discrimination. Six months after the media released her story, reporters reached out to surgeons who transformed Jorgensen from one gender to the other on the steps of the surgery. The surgeons released information that although Jorgensen removed her male genitalia, she did not have a vagina. Before this incident, the press assumed Jorgensen had a vagina. Her former supporters felt betrayed at the discovery and claimed she could not be a woman without ovaries and women’s other reproductive organs. Previously, Jorgensen avoided questions relating to her anatomy by focusing on her war background and physical appearance. The media soon shunned her and, according to author David Serlin, “they exposed her as an ‘altered male’-and, later, a ‘morbid’ transvestite… Jorgensen was seen as nothing more than a limp wristed queer who indulged in activities culturally identified as female and therefore effeminate.” She felt incomplete without a vagina until the day finally came, in May 1954, when Jorgensen underwent a vaginoplasty performed by Dr. Joseph Angelo and Dr. Harry Benjamin.

Jorgensen went on to be an entertainer and performed in many nightclubs. She wanted to be a Hollywood star but never made it big. She had several romantic relationships and was engaged twice, but unfortunately, she was denied a marriage license because her birth certificate identified her as a male. To compound her struggles, one of Jorgensen’s fiancés also lost his job when their engagement became known. However, she remained confident and optimistic about life, and in 1967, Jorgensen wrote an autobiography titled  Christine Jorgensen: A Personal Autobiography. Throughout her life, she received thousands of letters, both positive and negative, but the majority of the letters were from others with the same problems asking for help and guidance. She only wished that she could help all the individuals who reached out to her, but in a way she did by staying true to her identity and being a role model for others. Jorgensen went on to use her story to lecture at colleges across the United States on gender identity. Her life captivated and influenced so many that, in 1970, Hollywood created a film based on Jorgensen’s life called, The Christine Jorgensen Story.

Christine on the set during the filming of The Christine Jorgensen Story, meeting with actor John Hansen (who is portraying the “male” Jorgensen.) Image courtesy of TransasCity.org.

On May 3, 1989, Jorgensen died from bladder and lung cancer. Although gone, her incredible story still resonates and offers hope for transgender veterans as they pursue self-fulfillment. Jorgensen concluded that “The answer to the problem must not lie in sleeping pills and suicides that look like accidents, or in jail sentences, but rather in life and freedom to live it.”

Suggested Further Readings:   

Christine Jorgensen, Christine Jorgensen: A Personal Autobiography (New York: A Bantam Book/ published by arrangement with Paul S. Eriksson, Inc., 1967).  

David Serlin, Replaceable You: Engineering the Body in Postwar America (Chicago: University of Chicago Press, 2004).

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Inside The Pioneering Life Of Christine Jorgensen, U.S. Army Veteran And Trailblazing Transgender Activist

The first known american to undergo gender confirmation surgery, christine jorgensen became a culture icon in the 1950s..

Christine Jorgensen never intended to be a celebrity. But in 1952, she became famous overnight after undergoing sex reassignment surgery in Denmark. She was America’s first known trans woman to have the procedure, and she initially wanted to keep her surgery private.

Though Jorgensen only told her family members and close friends about her plans, someone leaked her story to the press, and before she knew it, she was on the front page of the New York Daily News . By the time she returned to the United States, she was mobbed by reporters who wanted to know every single detail about her physical transformation.

Bill Meurer/NY Daily News Archive via Getty Images Christine Jorgensen was one of the world’s first transgender celebrities.

Jorgensen, a World War II veteran who had once been desperate to fit in, decided to embrace her newfound fame as a transgender activist. Not only did she appear on talk shows and participate in lectures, but she also performed in nightclubs — often singing the song “I Enjoy Being a Girl.”

As she put it: “I decided if they wanted to see me, they’d have to pay for it.”

The Early Life Of Christine Jorgensen

Everett Collection Historical/Alamy Stock Photo Christine Jorgensen, back when she was known as George William Jorgensen, Jr., in the U.S. Army.

Assigned male at birth, Christine Jorgensen was given the name George William Jorgensen, Jr. when she was born in New York City on May 30, 1926. Raised in the Bronx, Jorgensen described her early self as a “frail, blond, introverted little boy who ran from fistfights and rough-and-tumble games.”

From a young age, Jorgensen recalled hating boys’ clothing and feeling as if she were trapped inside of a boy’s body. In high school, she felt as if she were “lost between two sexes,” and struggled with having crushes on boys. She took refuge in photography and the solitude of darkrooms.

After World War II broke out, she decided to enlist in the U.S. Army, but she was initially denied due to her small size. However, the Army later realized they didn’t have enough volunteers, and she was soon drafted. According to the National WWII Museum , she largely kept to herself during her service, hoping no one would find out about her struggles with her gender identity.

She said, “I wanted to be accepted by the army for two reasons. Foremost was my great desire to belong, to be needed, and to join the stream of activities around me. Second, I wanted my parents to be proud of me.”

Ultimately, she kept her inner struggles hidden and she was honorably discharged in December 1946, over a year after World War II ended.

After her service was complete, Jorgensen returned to her love of photography, even attending photography school in New Haven, Connecticut. But she still felt unhappy living her life as a young man. So when she learned about a new sex reassignment surgery being performed in Europe, she jumped at the opportunity to have the procedure herself.

Christine Jorgensen’s Stunning Transformation

NY Daily News/Getty Images Christine Jorgensen’s story made the front page of the New York Daily News , much to her surprise.

Christine Jorgensen devoured book after book, trying to figure out a solution to her ongoing problem. It was the book The Male Hormone that inspired her to start taking estrogen. She also began visiting doctors to see if there were any medical treatments that could help. However, most doctors simply described Jorgensen as “homosexual” since she was attracted to men.

Eventually, she learned about surgeons in Europe performing sex reassignment surgeries and became so interested in the procedure that she decided to travel to Denmark in 1950. There, she met with pioneering endocrinologist Dr. Christian Hamburger, who was the first medical expert to describe her as “transsexual” rather than “homosexual.” This helped pave the way for Jorgensen to receive gender confirmation surgery.

After being treated with hormone injections and attending psychotherapy sessions, Jorgensen slowly began undergoing the surgeries that would give her the physical transformation she wanted. She was so pleased with the results that she chose her new name Christine in honor of Dr. Hamburger.

She informed her family of her decision with an emotional letter, writing , “I have changed very much. But I want you to know that I am an extremely happy person… Nature made a mistake, which I have had corrected, and I am now your daughter.” She also included a few photos with the letter, so her loved ones wouldn’t be surprised by her new appearance.

Tom Gallagher/NY Daily News Archive via Getty Images Christine Jorgensen, pictured shortly after her return to the United States.

She also penned letters to her friends about the procedure, writing, “As you can see by the enclosed photos, taken just before the operation, I have changed a great deal. But it is the other changes that are so much more important. Remember the shy, miserable person who left America? Well, that person is no more and, as you can see, I’m in marvelous spirits.”

According to the New-York Historical Society , Jorgensen initially wanted to keep her surgery private. But someone who knew about her plans contacted the media, and her stunning transformation became front-page news on December 1, 1952. That day, the New York Daily News published before-and-after photos of Christine Jorgensen with the eye-catching headline “Ex-GI Becomes Blonde Beauty: Operations Transform Bronx Youth.”

By the time she returned to the United States in 1953, there were hundreds of reporters waiting to greet her at a New York City airport. Though she was well aware by that point that her story was now public knowledge, she quickly became overwhelmed by the attention after answering just a few questions. She said, “I thank you all coming, but I think it’s too much.”

However, she would eventually embrace her fame.

One Of The First Transgender Celebrities

Maurice Seymour/Wikimedia Commons Christine Jorgensen found success making appearances at both lectures and nightclubs.

Christine Jorgensen’s transformation led to mixed reactions across America. While some praised her for her “masculine,” patriotic past as a soldier and her physical beauty as an out trans woman, others mocked her by calling her an “altered male” and a “morbid transvestite.” Yet others continued to pry into her personal medical records, especially since she was not yet finished with all of her surgeries by the time her story broke. She would not receive her most coveted procedure, a vaginoplasty, until 1954.

Despite facing discrimination and interference into her personal life, Jorgensen saw a chance to make a living as a transgender celebrity. She also saw an opportunity to help other young trans women.

Eventually, Jorgensen found success making appearances on talk shows and participating in lectures. She also embarked on a series of performances at nightclubs. According to The New York Times , one of her signature songs that she performed during her act was the classic tune “I Enjoy Being a Girl.”

She also published a book, Christine Jorgensen: A Personal Autobiography , and her story was dramatized in the movie The Christine Jorgensen Story .

Wikimedia Commons Christine Jorgensen tried to marry her partner Howard J. Knox in 1959, but she wasn’t able to get a marriage certificate because her gender was still listed as “male” on her birth certificate. Ultimately, Jorgensen chose not to marry anyone.

Though Jorgensen had originally wanted to live a quiet life as a trans woman, she never regretted undergoing gender-affirming surgery. She said her family and friends were “understanding” about her decision. And even though not everyone in the public supported her, she believed that the publication of her story could help others who faced similar struggles .

She also said she gave the sexual revolution “a good swift kick in the pants.”

In her later years, Jorgensen was diagnosed with bladder and lung cancer. She died at age 62 on May 3, 1989 — but not before doing a few final interviews. In one of her last interviews, she said that although the general public knew more about transgender people than they did when she received gender confirmation surgery, there were still some things that people outside of the transgender community didn’t seem to comprehend.

As Jorgensen put it: “What people still don’t understand is that the important thing is identity. You don’t [transition] primarily for sexual reasons, you do it because of who you are.”

After reading about Christine Jorgensen, learn the stories of nine brave LGBTQ soldiers who were nearly forgotten by history . Then, go inside the murder of Brandon Teena , the trans man who inspired “Boys Don’t Cry.”

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Meet Oregonian Dr. Alan Hart, who underwent the first documented gender-confirming surgery in the US

It was 105 years ago that an Oregon doctor underwent what is thought to be the first documented gender-confirming surgery in the United States.

Dr. Alan Hart was born Alberta “Lucille” Hart in 1890. Hart grew up in the Willamette Valley and attended Albany College, now Lewis & Clark College. Hart preferred to present as male and did so as much as possible – often with family support. But at school, Hart was forced to wear dresses and appear as “Lucille.”

In 1917, Hart graduated with a medical degree from the University of Oregon Medical Department in Portland, now Oregon Health & Science University. That same year, Hart persuaded fellow Oregon doctor J. Allen Gilbert to perform what was — at the time —considered an unheard-of transition surgery. Hart underwent a hysterectomy, ensuring Hart could not have menses or become pregnant. That operation, along with a psychological evaluation, was enough for Dr. Gilbert to officially state that Hart should be accepted by society as a man.

“ From a sociological and psychological standpoint, she is a man. If society will but let her alone, she will fill her niche in the world and leave it better for her bravery. ” — Dr. J Allen Gilbert

Gilbert reported in a medical journal, “A hysterectomy was performed, her hair was cut, a complete male outfit was secured. She made her exit as a female and started as a male with a new hold on life.”

Alan Hart, circa 1922

Gay & Lesbian Archives of the Pacific Northwest

Within months of the surgery and transition, Hart legally changed his name and eloped with Portland schoolteacher Inez Stark. At the time, so-called “cross dressing” and same-sex marriage were illegal. Despite the risks, Hart came out openly in his hometown of Albany.

In 1918, Hart told the Albany Daily Democrat, “I had to do it. ... For years, I had been unhappy. With all the inclinations and desires of the boy. ... I have been happier since I made this change than I ever have in my life, and I will continue this way as long as I live. Very few people can understand.”

Many people didn’t understand. Throughout his career, he was outed and harassed, forcing him to move and change practices. His first marriage ended under that strain. Eventually, he married again and changed his career focus, graduating with a master’s degree in public health from Yale University. He would rise to the top of his field in treating and studying tuberculous. His pioneering work using x-rays for early detection is credited with saving thousands of lives.

Alan Hart's draft registration card.

public domain / Lewis & Clark College, Special Collections, Dr Alan L. Hart Collection

When Dr. Alan Hart died in 1962, his will instructed his attorney to destroy all of his personal papers, photographs, and records. Researchers rediscovered his story in the 1970s, but it remains largely unknown.

A compilation of Alan Hart’s college writings , along with an overview of Hart’s life, can be found online in the Lewis & Clark College Special Collections.

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History of Facial Feminization & Gender Confirmation Surgery

The Beginnings of Facial Feminization & Gender Confirmation Surgery

The Very First Known Case of Gender “Reassignment” Surgery

In 1906,  Karl “Martha” Baer  attempted suicide by stepping in front of a streetcar in Berlin after an affair with a married woman had been discovered. Baer was found to be presenting as male despite papers identifying him as female.

The Early, Experimental Years (1922-1969)

The origins of gender confirmation surgery can be traced back to the early 20th century when gender-related surgery was experimental and rare. One of the first identifiable recipients of gender confirmation surgery was  Rudolph “Dorchen” (Little Dora) Richter , who had an orchiectomy in 1922 by her own request at the  Institut für Sexualwissenschaft , founded by Magnus Hirschfeld in Berlin. Then later in 1930, she underwent penectomy by Dr. Levy-Lenz and then vaginal reconstruction by Dr. Gohrbrandt.

Lili Elbe, a Danish Transgender woman, was the next known case in 1930 . The first surgery (removal of the testicles) was made under the supervision of sexologist Magnus Hirschfeld in Berlin. The rest of her surgeries were carried out by Dr. Kurt Warnekros, a doctor at the Dresden Municipal Women’s Clinic.

During the 1950’s, transgender women benefited from newly available female sex hormone therapy. One of the pioneers in this field was German-born Psychiatrist and Sexologist,  Dr. Harry Benjamin , a peer of Dr. Hirschfield in the early 20th century in Germany. After immigrating to the United States, Dr. Benjamin became known internationally for his efforts to advance the field of non-surgical care for transgender individuals. He published papers and lectured to professional audiences extensively, and his book,  The Transsexual Phenomenon , was the first large work describing and explaining the affirmative treatment path he pioneered.

He also established the world’s first clinical psychiatric practice focused on the medical and psychological needs of the transgender individual. For over five decades, Benjamin conducted treatment in collaboration with carefully selected colleagues of various complementary disciplines for hundreds of patients with gender identity issues – and Christine Jorgensen was one of his early patients in the 1950s.

In 1952,  Christine Jørgensen , an American trans woman, had gender confirmation surgery in Denmark. When her transformation made the front page of the New York Daily News, she became an overnight sensation, and she used the opportunity to become a strong advocate for the rights of all transgender people.

MTF Gender Confirmation and Facial Feminization in the United States (1966-present)

The first male-to-female surgeries in the United States took place in 1966 at the Johns Hopkins University Medical Center. The first physician in the United States to perform gender confirmation surgery was the late Dr. Elmer Belt, who did so until the late 1960s.

Another notable person to transition was  Renée Richards . She underwent male-to-female gender confirmation surgery in the mid-1970s, and successfully fought to have transgender people recognized officially with their new gender.

Beginning in 1983,  facial feminization surgery (FFS)  (in addition to body-focused male-to-female gender confirmation surgery) was pioneered by  Dr. Douglas K. Ousterhout  in San Francisco. The popularity of facial gender confirmation has grown over the past 15 years for those pursuing male-to-female surgery.

Dr. Douglas Ousterhout – the Pioneer of Facial Feminization Surgery

Douglas K. Ousterhout, MD, DDS , is widely regarded as the world’s pioneer of facial gender confirmation.

After training with Dr. Paul Tessier, the father of craniofacial surgery, Dr. Ousterhout returned to San Francisco where he helped launch the Center for Craniofacial Anomalies at the University of California, San Francisco, Medical and Dental Centers.

His work at the Center for Craniofacial Anomalies at UCSF paved the way for his future focus–pioneering work and expertise in FFS.

Dr. Ousterhout began his private practice in San Francisco in 1973, making the practice one of the oldest continuing plastic surgery practices on the west coast. His specialty became facial feminization surgery for trans women, and he was widely considered the foremost facial feminization surgeon in the United States.

Dr. Douglas Ousterhout’s First Facial Feminization Surgery in 1983

In 1982, Dr. Ed Falces, a plastic surgeon who performed body-focused gender confirmation surgeries, approached Dr. Ousterhout with a request from “Lucy”, one of his male-to-female transgender patients. Lucy wanted plastic surgery to make her face appear more feminine. Dr. Ousterhout agreed to the collaboration with Dr. Falces and performed a  forehead feminization  procedure on Lucy – which involved the “ Ousterhout Type II ” forehead procedure.

Up until this point, Dr. Ousterhout’s practice had predominantly involved with reconstructing faces and skulls of people who had suffered birth defects, accidents, or other trauma. After assisting Dr. Pratt with Lucy, he was keen to understand better what was deemed a “female face” for future craniofacial procedures he might undertake.

Dr. Ousterhout conducted extensive research to identify which facial features were consituted feminine in shape and size. He derived measurements defining those features from a series of cephalograms taken in the 1970s, and then worked with a set of several hundred skulls to determine if he could consistently differentiate females and males using those measurements only.

Dr. Ousterhout then began adapting surgical techniques and materials he already used to transform and feminize the male face. For over two decades, he added more procedures and developed more aggressive techniques, with the goal of producing better outcomes and more attractive faces for transgender patients.

Just some of the new techniques and procedures he performed in FFS included advancing the hairline; making the forehead smaller and rounder; reducing the brow ridge; shortening and narrowing the nose; shortening the upper lip; shortening the chin; narrowing the jaw; and reducing the laryngeal prominence.

In 1998, Dr. Ousterhout left the University to devote approximately 80% of his practice time to the care of the transgender.

In 2006 he was one of only about twelve surgeons in the world performing FFS.

In the course of more than 30 years, he has performed thousands of successful facial feminization surgeries–seeing each patient as an individual who deserved to have their desired physical appearance and enhanced self-esteem. His contributions to patients and the medical community are unparalleled and he is known by the medical community as the pioneer of facial feminization surgery.

In addition to publishing well over a hundred scientific publications, Dr. Ousterhout published his medical textbook  Aesthetic Contouring of the Craniofacial Skeleton  in 1991. In 2009, he published  Facial Feminization Surgery , a guide for the prospective patient, which was based on having completed nearly seven thousand various procedures on eleven hundred patients.

Dr. Deschamps-braly Continues Dr. Ousterhout’s Legacy with Continued Innovation in the Field of Gender Reassignment Plastic Surgery.

Dr. Deschamps-Braly  is the only surgeon that Dr. Ousterhout has trained and mentored in the art and practice of gender facial confirmation surgery. He carries on the practice of a longstanding and innovative surgical practice in  Facial Feminization Surgery (FFS)  and now also groundbreaking work in  Facial Masculinization Surgery (FMS)  – incorporating the best of tradition and innovation in transgender plastic surgery.

In fact, Dr. Deschamps-Braly has just completed the world’s first  Adam’s apple augmentation via natural implant involving the insertion of an implant made from the patient’s own rib cartilage to increase the size of the Adam’s apple to make it appear more masculine.  Read more about facial masculinization here.

Like his mentor Dr. Ousterhout, Dr. Deschamps-Braly maintains a full surgical schedule, as well as a prolific academic career authoring numerous papers on craniofacial surgery. He also travels extensively presenting at various national and international conferences on a range of plastic and craniofacial surgery topics.

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Dec. 1, 1952: Ex-GI Becomes Blonde Beauty

1952: It's front-page news when George Jorgensen Jr. is reborn as Christine Jorgensen, gaining international celebrity and notoriety as the first widely known person to undergo a successful sex-change operation.

Jorgensen, who grew up in the Bronx, in her words, a "frail, tow-headed, introverted little boy who ran from fistfights and rough-and-tumble games," was drafted into the Army just after World War II. Military service only reinforced Jorgensen's belief that she was, in fact, a woman trapped inside a man's body .

After receiving her discharge, Jorgensen returned home and first heard about "sex-reassignment surgery," which was being performed only in Sweden. (It was illegal almost everywhere else, including the United States.)

Encouraged, Jorgensen began taking female hormones on her own, then headed for Sweden. She never made it. Stopping in Denmark to visit relatives in Copenhagen, Jorgensen was introduced to Christian Hamburger, a Danish surgeon who specialized in the kind of surgery she was seeking. He agreed to take the case and put his patient on hormone-replacement therapy as they prepared for surgery.

Several surgeries were required, the first one consisting of castration, which was only carried out after permission was obtained from the Danish minister of justice.

At the time of Jorgensen's transformation, Hamburger did not give her an artificial vagina, so she remained "anatomically incorrect" for several years before undergoing a vaginoplasty in the United States.

The hormone therapy resulted in profound changes to Jorgensen's body. Fat was redistributed, and she began to take on the contours of a woman. Subsequent surgeries completed the process until she was ready to step into the spotlight.

Jorgensen's sex change, which may have been leaked to the press by Jorgensen herself, hit the headlines Dec. 1, creating an international sensation. " Ex-GI Becomes Blonde Beauty " screamed the banner of Jorgensen's hometown New York Daily News.

In fact, Jorgensen was not the first person to undergo sex-reassignment surgery. During the rollicking Weimar period, German doctors performed the surgery on at least two patients. The difference, in Jorgensen's case, was that she underwent hormone-replacement therapy in conjunction with the surgery. The earlier surgeries were strictly cut-and-paste.

Although Jorgensen complained frequently about the jackals of the press, she did become something of a publicity hound and took most of the tasteless remarks with good grace, laughing off jokes such as, "Christine Jorgensen went abroad and came back a broad."

She turned to acting and became a nightclub singer as well, performing, predictably, "I Enjoy Being a Girl."

But Christine Jorgensen's world was not an enlightened one, particularly when it came to transgenderism. She paid the cost for this lack of sophistication. A first announced engagement fell through, and a second one failed as well, when the state of New York refused to issue the couple a marriage license. Her intended husband also lost his job when the marriage plans became known.

She later traveled the lecture circuit, talking about her experiences and advocating for the nascent transgender cause.

Jorgensen died of cancer in 1989, a few weeks short of age 63.

Source: Various

Photos: This 1975 triptych shows Christine Jorgensen when she was known as George in 1943, in 1952 immediately after her historic sex change, and in 1975 when she was nearing age 50. The center photo is the one she sent her parents in 1952, in a letter explaining the transformation. Jorgensen died in 1989. Bettmann/Corbis

This article first appeared on Wired.com Dec. 1, 2008.

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Introduction

The historic and cultural diversity of gender, biological underpinnings of gender identity, history of modern gender-affirming medical treatment, history of gender-affirming medical treatment in adolescents, changing prevalence of trans identities and the rise of nonbinary identification, legislative and social dynamics, conclusions, statement of ethics, conflict of interest statement, funding sources, author contributions, data availability statement, the evolution of adolescent gender-affirming care: an historical perspective.

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Jeremi M. Carswell , Ximena Lopez , Stephen M. Rosenthal; The Evolution of Adolescent Gender-Affirming Care: An Historical Perspective. Horm Res Paediatr 29 November 2022; 95 (6): 649–656. https://doi.org/10.1159/000526721

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While individuals have demonstrated gender diversity throughout history, the use of medication and/or surgery to bring a person’s physical sex characteristics into alignment with their gender identity is relatively recent, with origins in the first half of the 20th century. Adolescent gender-affirming care, however, did not emerge until the late 20th century and has been built upon pioneering work from the Netherlands, first published in 1998. Since that time, evolving protocols for gender-diverse adolescents have been incorporated into clinical practice guidelines and standards of care published by the Endocrine Society and World Professional Association for Transgender Health, respectively, and have been endorsed by major medical and mental health professional societies around the world. In addition, in recent decades, evidence has continued to emerge supporting the concept that gender identity is not simply a psychosocial construct but likely reflects a complex interplay of biological, environmental, and cultural factors. Notably, however, while there has been increased acceptance of gender diversity in some parts of the world, transgender adolescents and those who provide them with gender-affirming medical care, particularly in the USA, have been caught in the crosshairs of a culture war, with the risk of preventing access to care that published studies have indicated may be lifesaving. Despite such challenges and barriers to care, currently available evidence supports the benefits of an interdisciplinary model of gender-affirming medical care for transgender/gender-diverse adolescents. Further long-term safety and efficacy studies are needed to optimize such care.

The relatively recent recognition of diversity of “gender identity” – one’s inner sense of self as male or female or somewhere on the gender spectrum – in the current culture belies its long-standing presence in cultures diverse and ancient. “Transgender” (sometimes referred to as “gender incongruence”) is defined as a marked and persistent incongruence between an individual’s experienced gender and their sex designated at birth. Transgender is often used as an umbrella term to encompass all gender identities that are not the same as the birth-assigned gender (typically based on the sex designated at birth) but may also be used specifically for a binary gender identification.

As our understanding of gender has been evolving over time, so has the language used to describe gender. Throughout this manuscript, the authors have primarily used the terminology of the present day, though historical descriptions will contain language that is clearly outdated. We have chosen to use these terms only to maintain the historical perspective in this context.

Though it may seem that transgender as a concept is a recent phenomenon, there are both ancient and diverse examples that underscore the understanding that humans have experienced gender as beyond the set of cultural norms assigned to them based on their genitals. In Greek and Roman mythology, there are legends of deities who defy traditional concepts of gender; the most famous may be Hermaphroditus, a son born of Hermes and Aphrodite. When the nymph Salmacis fell in love with him, their forms became merged, with the god depicted as having male genitalia with breasts and a more feminine body shape [1, 2]. Norse mythology gives us the notorious shape and sex shifting Loki, who was known for his trickery, appearing at times in a female form when it suited his purpose [1]. Several Indigenous North American tribes have long-standing recognition and language for gender and/or sexual minority-identified individuals that often signified a third gender, or a combination of male and female. Though the designation and roles varied among tribes, the term “two-spirit” was coined in 1990 during the international LGBT Native American Gathering and attributed to Elder Maya Laramee [3, 4]. This term is not specific to any one tribe or any one group of individuals but encompasses any indigenous member with gender-diverse identification or same-sex attraction.

John Money, a New Zealand psychologist and faculty member in pediatrics at Johns Hopkins University beginning in the early 1950s, and co-founder of the Gender Identity Clinic at that university, promoted the concept that gender identity was influenced by “social learning and memory” in conjunction with biological factors [5]. However, a widely publicized case described in a book by John Colapinto published in 2000 lends strong support to the concept that gender identity is not primarily learned [6]. This book focused on a failed circumcision in an 8-month-old male resulting in loss of the penis, leading Money to advise the family to castrate the infant and raise him as a girl [6]. The child never accepted a female gender identity, became severely depressed, and changed gender to male during adolescence. He later committed suicide [6]. In subsequent years, evidence in support of biological underpinnings to gender identity development has continued to emerge, derived primarily from three biomedical disciplines: genetics, endocrinology, and neurobiology [7].

Starting in the late 1970s, heritability of being transgender was suggested from studies describing concordance of gender identity in monozygotic twin pairs and in father-son and brother-sister pairs [8, 9]. In the largest twin study evaluating gender identity, in which at least one member of a twin pair was transgender, there was a much greater likelihood that the other member of the twin pair was also transgender if they were identical versus nonidentical (but same sex) twins [ 10 ]. Attempts to identify polymorphisms in candidate genes that might be more prevalent in transgender versus cisgender individuals have been inconsistent. In particular, a 2009 study from Japan did not find any significant associations of transsexualism with polymorphisms in five candidate genes (encoding the androgen receptor, CYP19, ER-alpha, ER-beta, and the progesterone receptor) [ 11 ]. However, a 2019 study in 380 transgender women and 344 cisgender male controls demonstrated an over-representation of several allele combinations involving the androgen receptor in transgender women [ 12 ]. A subsequent study using whole-exome sequencing in a relatively small number of transgender males ( n = 13) and transgender females ( n = 17) demonstrated 21 variants in 19 genes that were associated with previously described estrogen receptor-activated pathways of sexually dimorphic brain development [ 13 ]. An association between polymorphisms in the estrogen receptor alpha gene promoter and a transgender male identity has also been reported [ 14 ].

The vast majority of transgender individuals do not have an intersex condition or any associated abnormality in sex steroid production or responsiveness [7]. However, studies in a variety of intersex conditions have informed our understanding of the potential role of hormones, particularly prenatal and early postnatal androgens, in gender identity development [7]. For example, several studies of 46,XX individuals with virilizing congenital adrenal hyperplasia caused by 21-hydroxylase deficiency demonstrated a greater prevalence of a transgender identity outcome (female to male) compared to the general population [ 15-17 ]. One such study published in 2006 demonstrated a relationship between severity of congenital adrenal hyperplasia and gender identity outcome, where 7% of patients with the severe salt-wasting form had gender dysphoria or a male gender identity, while no gender dysphoria was seen in any of the less severely affected individuals [ 16 ]. Studies in a variety of other hormonal and nonhormonal intersex conditions support a role of prenatal and/or postnatal androgens in gender identity development [7]. However, in 2011, a case report in a 46,XY individual with complete androgen insensitivity and a male gender identity challenged the concept that androgen receptor signaling is required for male gender identity development [ 18 ].

Neuroimaging studies that aim to understand the neurobiology of gender identity indicate that some sexually dimorphic brain structures are more closely aligned with gender identity than with physical sex characteristics in transgender adults prior to treatment with gender-affirming hormones [ 19-21 ]. A similar trend was reported in studies of gray matter in youth with gender dysphoria [ 22 ]. In 2021, an MRI study in transgender adults, also prior to treatment with gender-affirming sex hormones, found that transgender people have a unique brain phenotype “rather than being merely shifted towards either end of the male-female spectrum” [ 23 ]. Notably, in both transgender adolescents and adults, several functional brain studies looking at responses to odorous compounds or mental rotation tasks demonstrated that patterns typically observed to be sexually dimorphic were more closely aligned with gender identity than with physical sex characteristics, even before treatment with gender-affirming sex hormones [ 24-26 ].

Though individuals have demonstrated gender diversity throughout history, the use of medication and/or surgery is relatively recent with origins in Germany in the first half of the 20th century and is credited to the pioneering work of Magnus Hirschfeld. The institution he founded, “Institut für Sexualwissenschaft (the Institute for Sexual Science)” in Berlin (1922), paved the way for the use of hormones and surgery [ 27 ]. In Hirschfeld’s study of what he named “sexual intermediaries,” he recognized that people may be born with a nature contrary to their assigned gender. In cases where the desire to live as the opposite sex was strong, he thought science ought to provide a means of transition. Innovative for his time, he argued that a person may be born with characteristics that did not fit into heterosexual or binary categories and supported the idea that a “third sex” existed naturally [ 27 ]. The first documented case of genital surgery was performed at the institute on Dorchen Richter in 1922 with orchiectomy and then 1931 with penectomy and vaginoplasty [ 27, 28 ]. Notable patients, including Lili Elbe (born Einar Wegener), the patient on whom the movie “The Danish Girl” is based, underwent a series of operations including transplant of both ovaries and a uterus [ 29 ].

This clinic would be a century old if it had not fallen victim to Nazi ideology and Hitler’s mission to rid Germany of Lebensunwertes Leben, or “lives unworthy of living.” What began as a sterilization program ultimately led to the extermination of millions of Jews, Gypsies, Soviet, and Polish citizens, as well as homosexuals and transgender people. When the Nazis came for the institute in 1933, Hirschfeld had fled to France. Troops swarmed the building and created a bonfire that engulfed more than 20,000 of his books, some of them rare copies that had helped provide a history for transgender people [ 27 ].

In the 1950s, German-American physician Harry Benjamin (1885–1986) introduced the term “transsexuality,” defining a “transsexual” person as someone who identifies in opposition to their “biological sex” [ 30 ]. Harry Benjamin graduated cum laude from medical school in Tübingen, Germany, in 1912. He moved to New York City in 1914 to study tuberculosis, but over time, he became known as a geriatrician, endocrinologist, and sexologist [ 31 ]. He did not treat his first transgender patient until he was in his 60s, and his colleagues described him as follows: “Being a true physician, Benjamin treated all these patients as people and by respectfully listening to each individual voice, he learned from them what gender dysphoria was about” [ 32 ]. Notably, he did not describe “transsexualism” as a psychological problem, but as a biological condition that could be treated with hormone or surgical therapy [ 31 ]. He treated over 1,500 patients, and in 1966, he published the first medical textbook in this field, “The Transsexual Phenomenon” [ 33 ]. His work was very influential, and he became known as “The Father of Transsexualism” [ 31, 32 ].

Following World War II, gender-affirming treatment in the USA was limited to wealthy patients who could afford to travel to Europe, though they did so at great risk given the laws in several states outlawing “cross-dressing” [ 34 ]. Christine Jorgensen (1926–1989) brought visibility to transgender patients, having undergone medical and surgical transition in Europe after she had served time in the US military as a male [ 35 ].

Influenced by Dr. Benjamin Harris’ “The Transsexual Phenomenon” [ 33 ], Johns Hopkins Hospital in Baltimore became the first academic institution in the USA to offer gender-affirming surgery [ 36 ]. Soon after, at least another 8 academic institutions opened transgender programs throughout the 1960–1970s (University of Minnesota, University of Washington, Northwestern/Cook County Health in Chicago, Stanford University, Cleveland Clinic, University of Colorado, Baptist Medical Center in Oklahoma City, and Washington University in St. Louis) [ 37 ].

Toward the end of the 1970s, however, most transgender programs closed access to new patients. These closures were done quietly out of public view, and the causes were often not disclosed [ 37 ]. At Johns Hopkins Hospital, Paul McHugh became the Chair of Psychiatry in 1975. From the moment he was hired, McHugh openly stated he intended to stop gender-affirming surgery at this hospital [ 38 ]. Under his leadership, another Johns Hopkins psychiatrist, Dr. Jon Meyer, published a study of 50 patients which concluded that gender-affirming surgery did not provide “objective” benefit for transgender individuals [ 39 ]. This publication led to the sudden closure of the clinic in 1979 [ 36 ]. Interestingly, John Money, who believed that gender could be learned and who co-founded the Johns Hopkins gender clinic, publicly expressed opposition to Meyer’s conclusions of his study [ 36 ].

The program at the Baptist Medical Center in Oklahoma City had been functioning since 1973. However, in 1977, its existence was brought to the attention of the Board of Directors of the Baptist General Convention of Oklahoma. This led to a 54-2 vote by the Board of Directors at the Baptist Medical Center to close the program. Physicians who passionately advocated to continue this practice issued a joint statement saying, “If Jesus Christ were alive today, undoubtedly he would render help and comfort to the transsexual” [ 37 ].

It is thought that publicity around the Meyer paper [ 39 ] from Johns Hopkins played a role in an escalation of closure of other clinics [ 37 ]. Despite these closures, academic interest in the field led to the foundation of the Harry Benjamin Gender Dysphoria Association in 1979 [ 40 ]. This association had the goal of organizing professionals who were interested in the “study and care of transsexualism and gender dysphoria.” It has since been renamed the World Professional Association for Transgender Health (WPATH) and has evolved into a large international multidisciplinary organization that provides Standards of Care for the treatment of transgender/gender-diverse (TGD) adolescents and adults [ 41 ].

In 1980, “transsexualism” and “gender identity disorder of childhood” were both recognized as illnesses in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders [ 42 ]. In 2013, the term “gender identity disorder” was replaced by “gender dysphoria in children” and “gender dysphoria in adolescents and adults” to diagnose and treat those transgender individuals who felt distress at the mismatch between their gender identities and their bodies, with the American Psychiatric Association stating that “it is important to note that gender nonconformity is not in itself a mental disorder” [ 43 ].

In 2019, the World Health Organization International Classification of Diseases version 11 replaced International Classification of Diseases-10’s “transsexualism” and “gender identity disorder of children” with “gender incongruence of adolescence and adulthood” and “gender incongruence of childhood,” respectively [ 44 ]. Gender incongruence was moved out of the “Mental and behavioral disorders” chapter into a new chapter, entitled “Conditions related to sexual health” [ 44 ]. This reflects current perspective that TGD identities are not mental health illnesses and that classifying them as such can cause significant stigma.

Providers in the Netherlands recognized the importance of preventing progression of a gender incongruent puberty by using a gonadotropin hormone-releasing hormone analog (GnRHa) followed by treatment with either testosterone or estrogen to bring physical characteristics into alignment with a patient’s gender identity [ 45, 46 ]. This approach was first published by Drs. Cohen-Kettenis and van Goozen in 1998 in a case report of an adolescent treated with GnRHa by Dr. Henriette A. Delemarre-van de Waal (though not named in the publication) (Dr. Sabine E. Hannema , personal communication) [ 47 ]. Under the direction of Dr. Peggy Cohen-Kettenis, the first program geared to treating adolescents with gender dysphoria was established in the Netherlands [ 45 ]. Initially based on the guidelines of adult transgender treatment established by the Harry Benjamin Society and adapted to adolescents, patients first underwent comprehensive psychological assessment to establish a diagnosis of gender dysphoria (then called “gender identity disorder”) and then initiated treatment with GnRH agonists (GnRHa) typically at Tanner 2–3 to pause pubertal development [ 45, 46 ]. The time spent under pubertal suppression would be used to further explore gender identity prior to committing to either estrogen or testosterone and their physical effects. This intervention with a GnRHa would also be somewhat of a diagnostic aid in that if it eased the distress; it was reasonable to correlate the distress with gender dysphoria as a primary cause. This was followed by hormone therapy around age of 16 years and then gender-affirming genital surgery at 18 years or later [ 45, 46, 48 ]. The “Dutch Protocol” [ 49 ] was adapted by practitioners internationally, though it was not until pediatric endocrinologist and adolescent medicine pediatrician Dr. Norman Spack , having traveled to Amsterdam to observe the clinic there, established the first formal US program geared specifically to transgender adolescents at Boston Children’s Hospital: the Gender Management (subsequently replaced with Multispecialty) Service program in 2007 [ 50 ]. It should be noted that adolescents there and elsewhere across the USA had been treated outside of a structured program [ 50 ]. Clinical protocols at Gender Management Service were derived from direct observation, adaptation of the Dutch program, and a May 2005 consensus meeting (the Gender Identity Research and Education Society) and expanded upon previous guidelines from the Standards of Care of the WPATH and those from the Royal College of Psychiatrists [ 46, 51, 52 ].

The Endocrine Society guidelines, with input from the Pediatric Endocrine Society, the European Society for Paediatric Endocrinology, the European Society for Endocrinology, and WPATH, were first published in 2009 and recommended the use of GnRHa as a treatment for selected adolescents [ 53 ]. Pubertal suppression could be initiated when the individual reached Tanner 2 or 3, followed by gender-affirming hormones at age of 16 years. Subsequent standards of care and clinical practice guidelines published by WPATH (SOC 8 in 2022) [ 41 ], the University of California San Francisco in 2016 [ 54 ], and the Endocrine Society (updated in 2017) [ 55 ] continued to recommend treatment for adolescents starting with pubertal suppression at Tanner 2 and 3, with consideration of gender-affirming sex hormones in some adolescents younger than 16 years old (on a case-by-case basis) who had demonstrated strong and persistent gender dysphoria. Of note, the WPATH SOC 8 does not list minimum age requirements for gender-affirming medical care [ 41 ].

In 2014, a published resource guide providing contact information showed that there were 32 US and 2 Canadian programs available to treat TGD adolescents [ 56 ]. As of March 2022, there were about 60 recognized pediatric/adolescent multidisciplinary gender programs in the USA, though smaller programs and individual offices probably also provide care [ 57 ]. Some programs have been closed for political reasons with potentially dire consequences for both patients and practitioners [ 58 ].

Worldwide, the prevalence of people declaring a gender identity that is different from that assigned at birth has risen sharply as the recognition of gender diversity, and its social acceptance has increased. Early estimates of prevalence for those seeking hormonal treatment are notable for relatively low prevalence and a heavy predominance of birth-assigned males. In 1968, two authors published estimates demonstrating this trend. In the USA, Pauly cited 1:100,000 birth-assigned males and 1:400,000 birth-assigned females [ 59 ]. In Sweden, the estimate again favored the birth-assigned males at 1:37,000 and birth-assigned females at 1:103,000 [ 60 ]. By the mid-80s, numbers had risen with a similar ratio of birth-assigned males at 1:18,000 and birth-assigned females at 1:54,000 [ 61 ]. The same year, authors in Singapore reported much higher numbers of 1:2,900 and 1:8,300 birth-assigned males and females, respectively [ 62 ]. The Williams Institute of the University of California Los Angeles School of Law has tracked prevalence of transgender identification in the USA. A report from 2022 (based on data from 2017, 2019, and 2020) revealed that the prevalence of adults in the USA who identified as transgender has remained stable at around 0.5% of the population, or 1.3 million adults. However, the percentage of trans-identified youth (ages 13–17) had notably increased in recent years from 0.7% to 1.4% of the population [ 63 ]. Recent reports have also noted a rise in nonbinary gender identification and a reversal in the sex ratio of adolescents presenting for gender-affirming care from a predominance of those designated male at birth to a predominance of individuals designated female at birth. In 2017, a large adolescent multidisciplinary survey noted that 63% of the presenting patients were birth-assigned females [ 64 ].

Since 2016, many US states and European countries have introduced laws that restrict transgender youth from accessing gender-affirming care, team sports, and restrooms that are consistent with their gender identity [ 65 ]. Simultaneously, numerous reputable national and international academic medical societies have openly and repeatedly stated their opposition to these laws. This includes the Pediatric Endocrine Society [ 66, 67 ], the Endocrine Society [ 68, 69 ], the American Academy of Pediatrics [ 70 ], the American Medical Association [ 71 ], the United States Professional Association for Transgender Health [ 72 ], the American Association for Child and Adolescent Psychiatry [ 73 ], and in a united statement, also the American Psychiatric Association, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, and the American Osteopathic Association [ 74 ].These societies have stated that these bills are discriminatory and cause harm to the mental health of transgender youth. Despite this, some bills have passed successfully [ 65 ].

While there is a long-standing history acknowledging the existence of human gender diversity, the history of gender-affirming medical care for adolescents, in particular, is relatively brief. Evolving protocols for gender-diverse adolescents, first pioneered in the Netherlands, have been incorporated into clinical practice guidelines and standards of care published by the Endocrine Society and WPATH, respectively, and have been endorsed by major medical and mental health professional societies around the world. Notably, however, while there has been increased acceptance of gender diversity in some parts of the world, transgender adolescents and those who provide them with gender-affirming medical care, particularly in the USA, have been caught in the crosshairs of a culture war, with the risk of preventing access to care that published studies have indicated may be lifesaving. Despite such challenges and barriers to care, currently available evidence supports the benefits of an interdisciplinary model of gender-affirming medical care for transgender adolescents. Further long-term safety and efficacy studies are needed to optimize such care.

Not applicable as this is a historical report and not a report of research.

Jeremi M. Carswell, Ximena Lopez, and Stephen M. Rosenthal declare no conflicts of interest.

This work has not received any funding or financial support.

Jeremi M. Carswell, Ximena Lopez, and Stephen M. Rosenthal contributed equally to the writing of the manuscript. Jeremi Carswell and Ximena Lopez are the co-first authors, and Stephen M. Rosenthal is the senior and corresponding author.

There were no data generated for this report.

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The history of gender reassignment surgeries in the UK

For Pride Month, we are recognising the plastic surgeons who pioneered gender reassignment surgeries (GRS) in the UK. Gender reassignment surgery, also known as gender confirmation surgery or gender affirmation surgery, is a sub-speciality within plastic surgery, developed based on reconstructive procedures used in trauma and in congenital malformations. The specific procedures used for GRS have only been practised in the last 100 years.

Over the last decade, there has been an increase in society acknowledgement and acceptance of gender diverse persons. This catalysed an increase in referrals to gender identity clinics and an increase in the number of gender affirmation surgeries. GRS help by bringing fulfilment to many people who experience gender dysphoria. Gender dysphoria - a distress caused by the incongruence of a person's gender identity and their biological sex, drives the person to seek medical or surgical intervention to align some or all of their physical appearance with their gender identity. Patients with gender dysphoria experience higher rates of psychiatric disorders such as depression and anxiety. Gender-affirming medical intervention tends to resolve the psychiatric disorders that are a direct consequence of gender dysphoria.

Norman Haire (1892-1952) was a medical practitioner and a Sexologist. In his book, The Encyclopaedia of Sexual Knowledge (1933), he describes the first successful GRS. His patient, Dora Richter underwent 3 procedures reassigning from male to female between 1922-1931. The procedures included a vaginoplasty (surgical procedure where a vagina is created).

In the UK, gender reassignment surgeries were pioneered by Sir Harold Gillies. Harold Gillies is most famous for the development of a new method of facial reconstructive surgery, in 1917. During the Second World War, he organized plastic surgery units in various parts of Britain and inspired colleagues to do the same, training many doctors in this field. During the war, Gillies performed genital reconstruction surgeries for wounded soldiers.

British physician Laurence Michael Dillon (born Laura Maude Dillon) felt that they were not truly a woman. Gillies performed the first phalloplasty (surgery performed to construct the penis) on Dillon in 1946. In transitioning from female to male, Dillon underwent a total of 13 operations, over a period of 4 years.

Roberta Cowell (born Robert Marshall Cowell) is the first known Brit to undergo male to female GRS. After meeting Dillon and becoming close, Dillon operated illegally on Cowell. The operation helped her obtain documents confirming that she was intersex and have her birth gender formally re-registered as female. The operation that helped her transition was forbidden as it was considered “disfiguring” of a man who was otherwise qualified to serve in the military. Consequently, Gillies, assisted by American surgeon Ralph Millard performed a vaginoplasty on Roberta in 1951. The technique pioneered by Harold Gillies remained the standard for 40 years.

Gillies requested no publicity for his gender affirmation work.  In response to the objections received from his peers, he replied that he was satisfied by the patient's written sentiments: “To Sir Harold Gillies, I owe my life and my happiness”. “If it gives real happiness,” Gillies wrote of his procedures, “that is the most that any surgeon or medicine can give.” These words highlight the importance of plastic surgery in the mental wellbeing of transgender patients.

The BAPRAS Collection and Archive has an extraordinary assembly of fascinating archive and historical surgical instruments dating from 1900. Visit https://www.bapras.org.uk/professionals/About/bapras-archive or email [email protected] for more information.

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Olympic Boxer Imane Khelif Is Not a Trans Athlete

One controversy coming out of the 2024 paris olympics concerned a fight between algerian boxer imane khelif and italian boxer angela carini., alex kasprak, published aug. 2, 2024.

On Aug. 1, 2024, Algerian boxer Imane Khelif faced Italian boxer Angela Carini in an opening bout of the women's welterweight boxing tournament at the 2024 Paris Olympics. Forty-six seconds into the fight, after receiving a few punches, Carini ended the fight early, delivering an unusual win to Khelif.

Carini later said she ended the fight due to severe nose pain following one of Khelif's blows. Video showed her sobbing after her loss and not shaking Khelif's hand when offered to her. "I have never felt a punch like this," she said after the fight.

Anti-trans activists and social media pundits immediately painted this fight as an example of the alleged unfairness and danger of allowing trans women to fight against those assigned female at birth.

The author J.K. Rowling, for example, described the match on X as "a young female boxer" having "everything she's worked and trained for snatched away because [the International Olympic Committee] allowed a male to get in the ring with her."

The virulently anti-trans X account Libs of TikTok also weighed in , describing Khelif as "a man … being allowed to compete in women's Olympic boxing in Paris."

The problem with these arguments was Khelif is not trans. Khelif was born, and has lived her entire life, as a female. The sanctioned International Boxing Association (IBA) alleged in a confidential report she did not meet the World Boxing Championship requirements for female competition in 2023, despite having competed as a woman in that same competition for many years prior, winning silver in 2022.

Khelif's eligibility was challenged only after she beat a Russian opponent to advance to the World Championship quarterfinal round in 2023. The IBA was once recognized by the IOC as the official governing body for boxing — but that title was rescinded in April 2023 following, among other things, allegations of corruption and ties to Russian money . As a result, the IOC, not the IBA, sets the rules for Olympic women's boxing.

Who is Imane Khelif?

Khelif is an Algerian boxer who has competed, as a woman, at the international level for years. She has always identified as a woman, and as a UNICEF ambassador has discussed the role that being a young girl in a tiny rural village has had on her development as a boxer:

When Imane Khelif, 24, one of Algeria's top female boxers is asked what achievements she is most proud of, she says, "It's being able to overcome the obstacles in my life." Imane recalls how at 16 she managed to excel in football in her rural village in Tiaret in western Algeria despite football not being seen as a game fit for girls. Moreover, the boys in her village felt threatened and picked fights with her. Ironically it was her ability to dodge the boys' punches that got her into boxing.

She came in 17th at the 2018 IBA World Boxing Championships and 33rd in the 2019 IBA World Boxing Championships. She represented Algeria in the 2020 Tokyo Olympics. In those games, she lost to the tournament's bronze medalist, Ireland's Kellie Harrington. Her presence did not generate any controversy. She went on to win silver in the 2022 World Boxing Championships.

What Happened in 2023?

Khelif also competed in the 2023 IBA World Championships in New Delhi — that is, until she beat a Russian boxer. On March 22, 2023, Khelif " dominated " Russian boxer Amineva Azalia with a 4-1 victory, securing her a position in the quarterfinals scheduled to begin a few days later.

On March 24, however, the IBA disqualified Khelif, suggesting a "failure to meet the eligibility criteria for participating in the women's competition." In 2023, the head of the IBA told the Russian news agency TASS that DNA tests had "proved they had XY chromosomes and were thus excluded from the sports events." XY chromosomes are typically associated with males.

Responding to controversy a year later, however, the IBA more generally claimed that Khelif was "subject to [a] … recognized test" but that "the specifics remain confidential." The IOC had suggested the 2023 disqualification was due to her testosterone level, but the IBA pushed back on that claim.

Can Women Have XY Chromosomes or Elevated Testosterone?

Gender testing for women's sports remains controversial . The rationale is that the process of going through puberty as a male imparts significant physical advantages over females that could make competition between the sexes dangerous. The controversy, historically at least, has largely been over how these tests should work and how to handle cases complicated by the natural genetic diversity of human life.

There are genetic conditions, termed differences of sexual development, in which biological females are born with XY chromosomes but possess female anatomy, or that affect how a biological female regulates and reacts to testosterone, causing levels typically associated with males. Though there is no independent confirmation that Khelif has these conditions, people born this way would legally be considered female or intersex.

Debates over these issues in the context of women's sports have nothing to do with a purported "woke" or "trans agenda," because such instances involve women who were born as women, identify as women and have not undergone any sex reassignment surgery or procedure to change this fact. That is what IOC spokesperson Mark Adams meant when he clarified to the press "this is not a transgender issue."

Gender-reassignment procedures require significant financial and medical resources. The notion that a woman from a rural western Algerian village who sold scrap metal to support her boxing career would have had the ability to undergo such a procedure in a deeply conservative Muslim country that prohibits the practice is extremely unlikely , at best.

IOC Responds

On Aug. 1, 2024, the day Khelif defeated Carini, the IOC released a statement defending both Khelif and another boxer facing similar accusations, Taiwan's Lin Yu-ting:

We have seen in reports misleading information about two female athletes competing at the Olympic Games Paris 2024. The two athletes have been competing in international boxing competitions for many years in the women's category, including the Olympic Games Tokyo 2020, International Boxing Association (IBA) World Championships and IBA-sanctioned tournaments. … The current aggression against these two athletes is based entirely on this arbitrary decision, which was taken without any proper procedure – especially considering that these athletes had been competing in top-level competition for many years. Such an approach is contrary to good governance. Eligibility rules should not be changed during ongoing competition, and any rule change must follow appropriate processes and should be based on scientific evidence.

The IOC stated that both boxers have met the IOC eligibility requirements for competition as a woman in boxing.

Angela Carini Was Not Making a Political Statement

Social media accounts falsely attempting to make this story about transgender athletes attempted to paint a sorrowful picture of Carini's loss, describing her dreams as having been crushed by a man pretending to be a woman and suggesting that photos of the fight and of Carini's tearful reaction evoked images of domestic violence . Carini's tears and her not shaking Khelif's hand were used to support this narrative.

But according to The Associated Press, Carini was not making a political statement at all, and did not intend to refuse to shake Khelif's hand:

"All this controversy makes me sad," Carini said. "I'm sorry for my opponent, too. … If the IOC said she can fight, I respect that decision." Carini was apologetic for not shaking Khelif's hand after the bout. "It wasn't something I intended to do," Carini said. "Actually, I want to apologize to her and everyone else. I was angry because my Olympics had gone up in smoke. I don't have anything against Khelif. Actually, if I were to meet her again I would embrace her."

It is not uncommon for athletes of any gender to shed tears after losing a shot at a medal in the Olympic Games, nor is it uncommon for a punch to the head from an Olympic boxer to cause pain. Boxing is a sport in which two people try to punch each other hard enough to cause a knockout.

Bottom Line

The only purported evidence for the claim that Khelif is trans comes from an undisclosed test performed by an allegedly corrupt sports governing body that may have shown she has a DSD condition. The IOC has said Khelif meets its requirements for participation, with Adams, the IOC spokesman, specifically clarifying , "This is not a transgender issue."

Because Khelif is not transgender, claims attempting to make her victory against Carini an issue about transgender rights or "woke" politics are without basis.

Snopes reporter Jordan Liles contributed to this report.

"Algeria Boxer Imane Khelif Wins First Olympic Fight When Opponent Angela Carini Quits." AP News, 1 Aug. 2024, https://apnews.com/article/olympics-2024-boxing-gender-4b6eb881cce9c34484d30c68ad979127.

Boxing/Women's World Championships (Day 6): Algerian Imane Khelif Secures Her Ticket to the Quarter-Finals. https://al24news.com/fr/boxe-championnats-du-monde-feminin-6e-journee-lalgerienne-imane-khelif-valide-son-billet-pour-les-quarts-de-finale/. Accessed 2 Aug. 2024.

"Childhood of Boxer Imane Khelif as She Faces Accusations of Being 'Biological Male.'" The Independent, 2 Aug. 2024, https://www.independent.co.uk/news/uk/home-news/imane-khelif-olympics-boxer-trans-debate-gender-carini-b2590229.html.

Ewing, Lori. "Explainer: Olympics-DSD Rules in Focus in Women's Boxing." Reuters, 31 July 2024. www.reuters.com, https://www.reuters.com/sports/olympics/olympics-dsd-rules-focus-womens-boxing-2024-07-31/.

"Joint Paris 2024 Boxing Unit/IOC Statement." Olympics.Com, 1 Aug. 2024, https://olympics.com/ioc/news/joint-paris-2024-boxing-unit-ioc-statement.

"Lin Yu-Ting and Imane Khelif: Boxers Cleared for Paris Olympics." BBC Sport, 30 July 2024, https://www.bbc.com/sport/olympics/articles/c4ngr93d9pgo.

Newsweek. Olympics Officials Make It "Absolutely Clear" On Women Boxers Controversy. 2024. YouTube, https://www.youtube.com/watch?v=0do8voeKFNY.

"Olympic Association Calls for Successor to Run Boxing's Global Duties after Excluding IBA." BBC Sport, 9 Apr. 2024. www.bbc.com, https://www.bbc.com/sport/boxing/68773451.

"Statement Made by the International Boxing Association Regarding Athletes Disqualifications in World Boxing Championships 2023." IBA, 31 July 2024, https://www.iba.sport/news/statement-made-by-the-international-boxing-association-regarding-athletes-disqualifications-in-world-boxing-championships-2023.

Tokyo 2020: Harrington Guarantees Medal with Khelif Win. Aug. 2021. www.rte.ie, https://www.rte.ie/sport/olympics/2021/0803/1238700-tokyo-2020-harrington-guarantees-medal-with-khelif-win/.

"Who Is Italian Boxer Angela Carini and Why Did She Quit Her Fight against Imane Khelif?" AP News, 2 Aug. 2024, https://apnews.com/article/angela-carini-imane-khelif-boxing-63e9dbaa30f1e29196d4162c72c2babf.

By Alex Kasprak

Alex Kasprak is an investigative journalist and science writer reporting on scientific misinformation, online fraud, and financial crime.

Article Tags

Boxer previously barred from women’s events wins fight after opponent quits in 46 seconds

A female boxer whose gender identity has recently been questioned won her first fight at the Paris Olympics on Thursday.

Imane Khelif of Algeria defeated Angela Carini of Italy after Carini quit 46 seconds into the match. Carini stopped the fight after only a few punches were exchanged, avoided shaking Khelif’s hand and then fell to the floor in tears. 

Khelif’s participation in Olympic women’s boxing has been scrutinized in recent days after reports resurfaced that she and another boxer, Lin Yu‑ting of Taiwan, failed to meet gender eligibility tests at the Women’s World Boxing Championships in New Delhi last year. At the time, sporting officials alleged that the boxers failed an unspecified test because they had male chromosomes.

Khelif, 25, has always competed as a woman — including during the Tokyo Olympics — and there’s no indication that she identifies as transgender or intersex, the latter referring to people born with sex characteristics that do not fit strictly into the male-female gender binary.

Carini said she ended Thursday’s fight because she felt a “severe pain” in her nose. She added that she is not qualified to decide whether Khelif should have been allowed to compete.

“I am not here to judge or pass judgment,” Carini told reporters after the match. “If an athlete is this way, and in that sense it’s not right or it is right, it’s not up to me to decide.”

Others were less reserved.

“We have to pay attention, in an attempt to not discriminate, that we’re actually discriminating” against women, Italian Prime Minister Giorgia Meloni told reporters during a visit to the Olympic Village. “In these things what counts is your dedication, your head and character, but it also counts having a parity of arms.”

Several American politicians, including former President Donald Trump, Sen. Marco Rubio, R-Fla., and South Dakota Gov. Kristi Noem , also shared their views on the match.

“I WILL KEEP MEN OUT OF WOMEN’S SPORTS!” Trump wrote on his social media site, Truth Social .

Khelif’s win also provoked responses from several prominent figures who are frequently criticized for their remarks about transgender people.

“Harry Potter” author J.K. Rowling repeatedly referred to Khelif as “male” and called the match a “ brutal injustice ” in a series of posts on X.

Billionaire entrepreneur Elon Musk, who recently drew criticism for his comments about his estranged trans daughter , also weighed in on X, which he owns. Replying to a post that included a video of the fight and read “Kamala supports this…vote accordingly,” Musk, who endorsed Trump last month, wrote: “True or let her deny it.” 

While most of the responses online appear to be critical, Khelif was not without support. 

Ismaël Bennacer, who plays soccer for the Algerian national team, was among those who defended Khelif.

“Full support for our champion Imane Khelif, who is suffering a wave of unjustified hatred,” he wrote on X. “Her presence at the Olympic Games is simply the result of her talent and hard work.”

Khelif celebrated her win on social media, sharing a photo of herself from Thursday’s fight on Instagram and writing, “first Victory.” She did not address the criticisms in the post; she has said her disqualification from the world championships last year was a “conspiracy.” 

In a s tatement Thursday, the International Olympic Committee criticized the backlash directed at Khelif and Taiwan's Lin during the Olympics, as well as the decision by the International Boxing Association, or IBA, to disqualify them from last year's Women’s World Boxing Championships.

"The current aggression against these two athletes is based entirely on this arbitrary decision, which was taken without any proper procedure — especially considering that these athletes had been competing in top-level competition for many years," the statement said, in part. "Such an approach is contrary to good governance."

The IOC noted in its statement that it withdrew recognition of the IBA last year. The relationship was severed following years of governance and financial transparency issues, as well as perceived instances of corruption.

Instead of the IBA, the IOC refers to the Paris 2024 Boxing Unit — an ad-hoc unit it developed — for its eligibility standards. In Thursday's statement, the IOC said, "As with previous Olympic boxing competitions, the gender and age of the athletes are based on their passport."

The Algerian Olympic and Sports Committee did not respond to a request for comment about the criticisms surrounding Khelif’s win.

Abderrahmane Hammad, Algeria’s minister of youth and sports, addressed concerns over Khelif’s gender identity Wednesday.

“I strongly condemn the baseless attacks on our athlete, Imane Khelif, by certain foreign outlets,” he wrote on X . “These cowardly attempts to tarnish her reputation are utterly unacceptable.”

Related stories:

• Boxers previously barred from women's events will fight in Paris Olympics
• Team USA's Lauren Scruggs on winning silver in fencing and making Olympic history
• A record 193 LGBTQ athletes to compete in Paris Olympics

In a series of posts on social media Thursday, the Algerian Olympic and Sports Committee celebrated Khelif’s win.

“We are proud of you and look forward to seeing you shine even more in the next stages,” one of the translated Facebook posts said.

Khelif’s next match is against Hungary’s Luca Anna Hamori in Saturday’s women’s 66-kilogram quarterfinals .

Matt Lavietes is a reporter for NBC Out.

Olympic officials address gender eligibility as boxers prepare to fight

PARIS – The case of two Olympic boxers has drawn attention to a thorny issue: Who and what determines which female athletes can compete.

Algerian boxer Imane Khelif and Lin Yu-ting of Taiwan both were disqualified from the 2023 women’s boxing world championships when they reportedly failed gender eligibility tests.

But this week, the International Olympic Committee confirmed the two boxers have been cleared to compete here at the Paris Games , as they both did at the Tokyo Games in 2021. The issues of so-called gender verification or sex testing have fueled discussion at the Olympics as the fighters prepare to enter the ring at North Paris Arena.

Khelif, a silver medalist at the 2022 world championships, is scheduled to fight Thursday against Angela Carini of Italy in the welterweight division at 146 pounds. Lin, a two-time world champion, is scheduled to fight Sitora Turdibekova of Uzbekistan in the featherweight division at 126 pounds.

“Yeah, it’s really tricky," Australian boxer Tiana Echegaray told reporters Tuesday when asked about the situation. "I don’t know exactly what their circumstances are."

IOC spokesman Mark Adams indicated Tuesday no personal information about the boxers' medical histories would be disclosed. "They've been competing in boxing for a very long time," Adams told reporters. “They've achieved all the eligibility requirements in terms of sex and age. We're following the rules in place in Tokyo."

Who's in charge of boxing?

At the Summer Olympics, when it comes to gender eligibility, the IOC defers to the international federations that govern each of the 32 sports.

The IOC does provide a framework to the international federations . But it's “nonbinding."

In other words, it’s not up to the IOC. And the situation has grown especially complicated with boxing.

Last year the IOC banished the International Boxing Association (IBA), long plagued with scandal and controversy that jeopardized the future of Olympic boxing. In fact, the IOC denied IBA the right to run Olympic boxing during the Tokyo Games in 2021 and instead turned over control to an ad-hoc unit.

Opinion: Olympic female boxers are being attacked. Let's just slow down and look at the facts

With that ad-hoc unit in charge, Kehlif and Lin both competed at the Tokyo Olympics. Neither won a medal.

But the IBA has maintained control of the world championships and gender eligibility rules. And after Lin won gold and Kehlif won bronze at the event in March 2023, officials announced the boxers had failed medical eligibility tests and stripped them of the medals.

IBA president Umar Kremlev said DNA tests “proved they had XY chromosomes and were thus excluded."

What's the eligibility criteria?

A passport could be key, based on comments from Adams, the IOC spokesman.

“I would just say that everyone competing in the women’s category is complying with the competition eligibility rules," he said. “They are women in their passports and it is stated that is the case.”

Thursday Adams added that the issues with the previous tests for the boxers "was not a transgender issue, there's been some misreporting on that in press. ... These women have been competing as women for many years.

"What I would say just quickly on testosterone is, the testosterone (test) is not a perfect test. Many women can have testosterone, even what would be called 'male levels' and still be women and still compete as women. So this is not a panacea − this idea that suddenly you test, do one test for testosterone. Each sport needs to deal with this issue but I think we agreed, I hope we're agreed, we're not going to go back to the bad old days of 'sex testing'. That would be a bad idea."

In the past, other eligibility standards have hinged on science.

Caster Semenya, a two-time Olympic gold medalist in track and field in 2012 and 2016, was forced to give up competing in the 800 meters because her testosterone levels were too high based on tests administered by World Athletics, the sport’s international federation previously known as the IAAF.

Semenya was assigned female at birth. She said she was told at age 18 that she has XY chromosomes and naturally had high levels of testosterone.

Khelif and Lin have not publicly addressed details of their medical histories regarding the tests.

The issue of eligibility surfaced as a source of controversy in the United States in 2022 when swimmer Lia Thomas became the first openly transgender athlete to win an NCAA championship.

At the time, the NCAA required transgender female athletes to have undergone one year of testosterone suppression treatment to be eligible to compete on a women's team in any sport. The NCAA has been under pressure to update its guidelines after the NAIA banned all transgender athletes from competing in women's sports.

The Court of Arbitration for Sport upheld a decision in June by World Aquatics, the international federation for swimming, that prevented Thomas from competing in elite competitions through World Aquatics or USA Swimming.

Who are these two boxers?

Lin, 28, has been fighting as an amateur for more than a decade, according to BoxRec, a widely regarded boxing site.

She made her official amateur debut about three months shy of her 18th birthday, winning at the 2013 AIBA World Women’s Championships. She won gold medals at the world championships in 2019 and 2022.

At 5-foot-9, she often has enjoyed a height advantage while amassing a record of 40-14 with one knockout. The record does not reflect the four fights she won at the 2023 world championships before her disqualification, which resulted in the outcome of the fights being changed to “no contest.’’

She lost her last fight – a split-decision defeat against Brazil’s Jucielen Cerqueira Romeu in April at the 2024 USA Boxing International Invitational in Pueblo, Colorado.

Khelif, 25, made her amateur debut at the 2018 Balkan Women's Tournament. She won a silver medal at the 2022 world championships.

At 5-foot-10, she also has enjoyed a height advantage while amassing a record of 36-9 with four knockouts, according to BoxRec. That does not include the three fights she won at the 2023 world championships before her disqualification resulted in the fights being changed to “no contest.’’

In one of those fights, Khelif stopped her opponent by TKO.

Contributing: Kim Hjelmgaard

Ontario transgender woman loses fight to have province pay for facial feminization surgery

'Where do we draw the line?' Some doctors argue Canadian provinces should pay for facial gender-affirming surgery so trans women can 'pass' as female

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A transgender woman has lost her appeal to have Ontario pay for surgery to soften her masculine facial features.

Facial feminization surgery can provide results that can’t be achieved with hormones alone, surgeons have reported, and can allow trans feminine individuals “to be recognizable as women to others.”

But critics say governments must draw the line somewhere.

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“Why should this quickly growing identity group be entitled to services that others are not,” said Pamela Buffone, founder of the Canadian Gender Report.

In the Ontario case, the transgender woman, M.F., who suffers from severe gender dysphoria, and whose identity is protected under a publication ban, sought surgery for a pronounced Adam’s apple and prominent forehead, facial characteristics that don’t align with her self-identified gender.

M.F. received a letter last September from Ontario’s health insurer, denying her request for approval of payment to undergo a tracheal shave and brow reduction at a Montreal clinic specializing in facial feminization surgery, or, alternatively, in Ontario, if need be. Administrators of the Ontario Health Insurance Plan (OHIP) argued that the procedures sought aren’t insured services under the Schedule of Benefits, and therefore not eligible for payment. The patient appealed to Ontario’s Health Services Appeal and Review Board, which upheld OHIP’s decision in a recently published ruling.

In  submissions filed in the written hearing, M.F. wrote that her gender dysphoria is getting worse as she gets older, that her facial features “are causing her severe daily distress” and that she “hates being visibly transgender,” according to the board’s written decision. She argued that facial feminization surgery is necessary to cure her gender dysphoria. She has been on hormone therapy for more than a year but has “certain facial characteristics that are associated with males” because she went through male puberty.

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Since OHIP pays for “medically necessary” gender reassignment surgeries, M.F. argued that the province should also agree to cover the requested facial surgeries, which would cost less — roughly $15,000 to $30,000, depending on what’s done — than if she were seeking genital surgery.

She argued that the emphasis on sex reassignment surgery “reinforces outdated beliefs about there being only one way to transition and that many transgender people do not want genital surgery.”

OHIP, however, denied M.F’s request for surgery to reduce her Adam’s apple and reconfigure her brow, arguing the “specific sex reassignment surgery” she is seeking isn’t included among the gender-affirming procedures Ontario does cover, like external genital surgery, hysterectomies or mastectomies.

While acknowledging her argument that the facial feminization surgeries are medically necessary for her, the appeal board denied her appeal. The regulations are clear that a service must be referred to in the Schedule of Benefits in order to be eligible, the three-member panel ruled.

Last year, an appeal board panel ruled that Ontario should pay for a non-binary resident who identifies as neither fully female nor fully male to have surgery to create a vaginal opening while leaving their penis intact , a “penile sparing vaginoplasty” than can cost upwards of US$70,000.

Yukon and Prince Edward Island are the only jurisdictions in Canada that cover facial feminization surgery, however, in 2021, a Manitoba trans woman successfully appealed Manitoba’s refusal to pay for facial surgeries.

“It is often easier, medically, for trans men to achieve changes that will result in passing,” said Dr. Sarah Fraser, a Halifax family physician who regularly treats trans and gender diverse people.

Pass is a term used more colloquially, Fraser said, “but, basically it means to be able to fit into society recognizable as one’s gender identity, instead of being perceived as the sex assigned at birth.”

“But for trans women, that can be a lot more difficult, especially in the case of this person (in Ontario) who has a prominent Adam’s apple,” said Fraser, who argued for public funding for minimally invasive procedures, like injectable fillers, Botox, and hair removal via lasers and electrolysis in a commentary published in the Canadian Medical Association Journal.

Even with access to hormone therapy, “the desired aesthetic effects often take months to years to manifest,” Fraser and her co-author, Dr. Katie Ross, wrote.

Facial feminization surgery isn’t a minor procedure. It’s major surgery, Fraser said. Still, “I think it’s absolutely legitimate that this person was applying for public funding and I frankly think that it should be covered across the board,” along with minor cosmetic procedures, she said.

“When you look at the mental health of people who are trans and gender diverse, these surgeries can impact mental health substantially,” Fraser said. One study published in the journal, Annals of Surgery, found trans feminine patients who had undergone facial surgery reported less depression, less anxiety and less social isolation compared to a pre-surgery group.

“There is still a sense out there that these surgeries are considered aesthetic, or superfluous or something extra, and I think the concerns aren’t taken seriously because of the discrimination that exists at its roots,” Fraser said.

Facial feminization surgery “is just as important as genital surgery,” she said. “It’s your face that you’re presenting to the world when you’re getting a job and when you’re out and interacting with the public on a day-to-day basis.”

Ontario’s ministry of health did not respond to a request for comment before deadline.

“The question for our health-care system is, what is medically necessary and which procedures should be publicly funded,” Buffone, of Canadian Gender Report, said in an email. “There are cancer patients who are left disfigured and distressed but who are not entitled to publicly funded facial surgeries or minor cosmetic procedures to reconstruct their appearance.

“What (M.F.) is requesting is for our health-care system to give special status to people who identify with this amorphous group called ‘trans’ and cater to any and every whim they have. Where do we draw the line?”

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What happened with Imane Khelif, boxer who had gender test issue, at Olympics?

Khelif was disqualified from the 2023 world championships after failing an unspecified gender eligibility test, and her presence at the paris olympics has become a divisive issue, by nbc chicago staff and greg beacham | the associated press • published august 1, 2024 • updated on august 2, 2024 at 12:33 pm.

UPDATE: The latest updates on this story, including if Khelif will box again, can be found here . Our original story continues below.

Imane Khelif of Algeria won her opening Olympic boxing bout Thursday when opponent Angela Carini of Italy quit after just 46 seconds in an unexpected and highly unusual moment, but what exactly caused it?

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Carini set the record straight following the headline-making moment.

Here's what to know:

What happened in the Imane Khelif-Angela Carini match?

Carini and Khelif exchanged only a few punches before Carini walked away and abandoned the bout — an extremely unusual occurrence in Olympic boxing.

Carini’s headgear apparently became dislodged at least once before she quit.

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Carini didn't shake Khelif's hand after the decision was announced but cried in the ring on her knees.

Who is Imane Khelif?

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Khelif was disqualified from the 2023 world championships after failing an unspecified gender eligibility test, and her presence at the  Paris Olympics  has become a divisive issue.

Khelif is an accomplished amateur who won a silver medal at the International Boxing Association's 2022 world championships. The same governing body disqualified her from last year's championships shortly before her gold-medal match because of what it claimed were elevated levels of testosterone.

The 25-year-old entered the ring at the North Paris Arena to a chorus of cheers, but the crowd was confused by the bout's sudden end. Khelif, who fights again Saturday, didn't speak to reporters.

What did Carini say?

After the match, a still-tearful Carini said she quit because of intense pain in her nose after the opening punches. Carini, who had a spot of blood on her trunks, said she wasn't making a political statement and was not refusing to fight Khelif.

“I felt a severe pain in my nose, and with the maturity of a boxer, I said ‘enough,’ because I didn’t want to, I didn’t want to, I couldn’t finish the match," Carini said.

Carini further said she is not qualified to decide whether Khelif should be allowed to compete, but she had no problem fighting her.

“I am not here to judge or pass judgment,” Carini said. "If an athlete is this way, and in that sense it’s not right or it is right, it’s not up to me to decide. I just did my job as a boxer. I got into the ring and fought. I did it with my head held high and with a broken heart for not having finished the last kilometer.”

Carini said she was "heartbroken" by her decision.

“I am heartbroken because I am a fighter," Carini said. “My father taught me to be a warrior. I have always stepped into the ring with honor and I have always (served) my country with loyalty. And this time I couldn’t do it because I couldn’t fight anymore, and so I ended the match.”

What else to know about the controversy

Khelif and Lin Yu‑ting of Taiwan suddenly have received  massive scrutiny for their presence in Paris  after years of amateur competition. Lin won IBA world championships in 2018 and 2022, but the governing body stripped her of a bronze medal last year because it claimed she failed to meet unspecified eligibility requirements in a biochemical test.

Lin begins her Paris run Friday, fighting Uzbekistan’s Sitora Turdibekova in her opening bout after receiving a first-round bye.

The Algerian Olympic Committee issued a statement Wednesday condemning what it termed “lies” and “unethical targeting and maligning of our esteemed athlete, Imane Khelif, with baseless propaganda from certain foreign media outlets.”

Italian Premier Giorgia Meloni, who was visiting Italy athletes in the Olympic Village on Thursday, voiced criticism that Carini had to box Khelif, saying she had since 2021 opposed allowing athletes with “genetically male” characteristics to compete against women.

“We have to pay attention, in an attempt to not discriminate, that we’re actually discriminating,” against women’s rights, Meloni said.

She said it was necessary to guarantee the rights of athletes so they are competing on an even playing field.

“In these things what counts is your dedication, your head and character, but it also counts having a parity of arms,” Meloni said.

Khelif and Lin are two-time Olympians who fought in the Tokyo Games with no controversy. Lin has been an elite-level amateur boxer for a decade and Khelif for six years. They were allowed to compete in Paris by the IOC task force, which has run the past two Olympic boxing tournaments.

The IOC on Tuesday defended their right to compete. Olympic boxing reached gender parity for the first time this year, with 124 men and 124 women competing in Paris.

“Everyone competing in the women’s category is complying with the competition eligibility rules,” IOC spokesperson Mark Adams said. ”They are women in their passports and it’s stated that this is the case, that they are female.”

Lin is the top seed in the 57-kilogram category, although Olympic seeding is frequently unindicative of the top medal contenders in a division.

Several sports have updated their gender rules over the past three years, including  World Aquatics ,  World Athletics  and the  International Cycling Union . The track body also last year tightened rules on athletes with differences in sex development.

The IOC said it made its eligibility decisions on boxers based on the gender-related rules that applied at the 2016 Rio de Janeiro Olympics.

The IOC is in charge of boxing in Paris because  the IBA has been banned  from the past two Olympics because of years of governance problems, a lack of financial transparency and many perceived instances of corruption in judging and refereeing.

The IOC has revoked the Olympic status of the IBA, which is controlled by president Umar Kremlev, who is Russian. He brought in Russian state-owned Gazprom as its primary sponsor and moved much of the IBA’s operations to Russia.

The IBA has since lost more than three dozen members who have formed a new group called World Boxing,  which hopes to be recognized by the IOC  as the sport’s governing body ahead of the 2028 Los Angeles Games.

The IBA has aggressively seized on the boxers’ presence in Paris to criticize the IOC. After the Court of Arbitration for Sport upheld the IOC’s ban earlier this year, the IBA appealed to the Swiss Federal Tribunal.

The banned body issued a statement Wednesday in which it claimed both boxers did not have a “testosterone examination” last year but were “subject to a separate and recognized test” for their disqualification. The IBA said the test’s “specifics remain confidential,” refusing to explain it.

Women’s boxers have been asked about Khelif and Lin repeatedly this week. Many have expressed concern, while others have urged more consideration of an obviously complicated issue.

“I don’t agree with that being allowed, especially in combat sports as it can be incredibly dangerous,” Australia middleweight Caitlin Parker said. “But right now, my focus is on getting through each fight. It’s not like I haven’t sparred with guys before, but it can be dangerous for combat sports, and it should be seriously looked into. It is good that these things are coming out, and it’s being put under the spotlight to be looked into further.

“Biologically and genetically, they are going to have more advantages. Combat sports can be dangerous. Fairness is what it’s all about. We all want fairness in sport.”

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