when was the first gender reassignment surgery in the uk

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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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Nov 12, 2018

Written By Sophie Nevrkla

The history of transgender rights in the UK

The battle over gender rights and identity has taken on huge significance in the past few years. But our understanding of transgender issues has a long and complex history, which is helping shape the present legal landscape.

In 1951, Roberta Cowell made history as the first known British trans woman to undergo gender-reassignment surgery. ‘Betty’ Cowell, formerly ‘Bob’, had previously been a racing driver and a Spitfire pilot in the Second World War, happily married with two children. After telling her wife about her plans to transition, her wife severed all contact, and Roberta’s children—Anne, six and Diana, four—grew up without any knowledge of their missing father. Roberta Cowell died in 2011 in her flat in west London, alone, with just half a dozen people at her funeral.

Since Cowell’s transition, knowledge and awareness of transgender people has grown by a significant margin. Gradually, the word ‘transsexual’ has been phased out in favour of ‘transgender’, a more inclusive term to describe someone who doesn’t identify with the gender they have been assigned at birth, but may not have had gender reassignment surgery.

Since 2000, the legal rights of trans people have begun to be entrenched more seriously in UK law. Since Caitlin Jenner came out as a woman in April 2015, an even brighter media spotlight has been placed on the trans community, particularly on trans women, and celebrity activists such as Laverne Cox and Munroe Bergdorf have worked to promote the cause and link it to wider struggles for equality happening in the UK, the US and across the world.

In 1963, fashion model April Ashley (who transitioned to become physically female in 1960) and Arthur Corbett married; by 1963, the marriage had broken down. When the marriage was eventually annulled in 1970, it was on the basis that the court considered Ashley to be male, though Corbett had been aware of Ashley’s transition at the time they wed. What came to be known as the Corbett v Corbett divorce case established the legal precedent that a person’s sex couldn’t legally be changed from that which is assigned at birth. From Corbett v Corbett onwards, members of the trans community were confined to an awkward space, unable to inhabit fully their genders and bodies in the eyes of UK law or society.

As the 20th century progressed, more and more trans people begin to take cases to court on the grounds of discrimination in the workplace and wider society. In 1986, trans man Mark Rees brought a case to the European Court of Human Rights, complaining that UK law prevented him from gaining legal status that recognised him as male. Though he didn’t win his case, the court discussed at length the legal marginalisation of the trans community—a theme that would be revisited in Goodwin v United Kingdom (2002).

The workplace, too, provided a space for discrimination. In 1996, the milestone case P v S and Cornwall County Council saw that a woman, named as P in court proceedings, had been dismissed from her workplace after informing employers that she was undergoing gender-reassignment surgery. After taking her employers to an employment tribunal, the court ruled that she was wrongfully dismissed; it became the first piece of case law to prevent discrimination in employment or vocational education on the basis of someone being trans. These subtle shifts in the 1980s and 1990s set the stage for more changes during the course of the 21st century. The early 2000s saw the slow beginnings of the legislative codification of trans rights under successive Labour governments.

In this more liberal climate, Goodwin v United Kingdom (2002) provided landmark change for the trans community. Christine Goodwin had faced sexual harassment at work during and subsequent to her gender reassignment. She complained to the court that due to her male legal status, she was forced to pay National Insurance contributions until the age of 65 rather than 60. Goodwin also stated that because her NI number must remain the same under UK law, her employer was able to find out that she had worked for the company previously under a different name and gender, which resulted in more humiliation and harassment. Further to this, the court heard that another woman, referred to as ‘I’ in court proceedings, had been refused a place on a nursing course after she refused to present her birth certificate. 

The individuals protested the lack of legal recognition of trans people, their gender and their post-operative sex, and their poor treatment with respect to employment, social security and pensions, as well as their inability to get married as either male or female. The European Court of Human Rights ruled in 2002 that UK law violated the right of transgender people to a private life, and the right to marry and start a family. Judges ruled that the UK Government should help trans people by issuing new birth certificates to reflect their gender identity, and permit their marriage to an individual of the opposite gender. Here, the Government was held directly accountable for the lack of protections for the trans community. For the first time, the lawmakers were forced to provide for the oppressed minority, recognising their gender identity and right to the same freedoms as other individuals.

This UK Government’s loss of the Goodwin case resulted in the introduction of the Gender Recognition Act in 2004, perhaps the most significant and wide-reaching piece of trans-focused legislation. Under the Act, the government awarded trans people full legal gender recognition and allowed them to acquire new birth certificates. Rather than being denied or dismissed, trans people had their personal identity recognised here for the first time in UK law. These moves towards acceptance culminated in the Equality Act of 2010, which, among other things, banned discrimination in the workplace and wider society on the basis of gender reassignment.

Despite these steps, UK law still reflects a limited understanding of the nuances that exist within transgender identity. Birth certificates and passports in the UK still only allow for the options ‘male’ or ‘female’, meaning that non-binary individuals aren’t recognised by law. Other western states are leading the way: Ontario became the first Canadian province to offer non-binary options on birth certificates in March 2018, denoted by an ‘X’. Though Gendered Intelligence was founded in the UK in 2008 to spread understanding of gender diversity, it’s only over the course of the last few years that the concerns of nonbinary individuals have been included in the wider conversation about trans rights. Perhaps enacting legislation to promote the ‘they’, rather than simply the ‘he’ or ‘she’, will be the next big shift over the following decades, as our perception of ‘gender’ changes and develops.

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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.

Brief History of Gender Affirmation Medicine and Surgery

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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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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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The Lawfulness of Gender Reassignment Surgery

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• 10.1093/ajlh/njx032
• The lawfulness of gender_LEWIS_Accepted26October2017_GREEN AAM Accepted author manuscript, 1.36 MB

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• Gender Social Sciences 100%
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T1 - The Lawfulness of Gender Reassignment Surgery

AU - Lewis, Penney

PY - 2018/3/31

Y1 - 2018/3/31

N2 - In the common law world, both the medical and legal professions initially considered gender reassignment surgery to be unlawful when first practised and discussed in the first half of the twentieth century. While most medical procedures are covered by the medical exception to the law governing serious offences against the person, many doctors and the lawyers they consulted doubted that this exception applied to gender reassignment surgery. In this article I trace the differing and changing interpretations of the medical exception as applied to gender reassignment surgery, and the shift towards legal acceptance in the two common law jurisdictions that led the way in both performing gender reassignment surgery and debating its legality, the United States and the United Kingdom. Although this shift occurred without formal legal intervention either through legislation or judicial decision (for example on a test case), inferences of legality drawn from related civil-law decisions bolstered the legal acceptance of gender reassignment surgery.By increasing the suffering of patients and potential patients, the criminal law played both an important and primarily malign role prior to the eventual public, professional and legal acceptance of GRS. A real threat of criminal prosecution inhibited doctors from proceeding, distorted diagnoses and affected the kinds of procedures performed. After-care was expanded and manipulated to avoid the risk of prosecution or the appearance of unlawful surgery. By contrast, civil and administrative law played a more positive, albeit indirect, role in interpreting the medical exception and its application to gender reassignment surgery.

AB - In the common law world, both the medical and legal professions initially considered gender reassignment surgery to be unlawful when first practised and discussed in the first half of the twentieth century. While most medical procedures are covered by the medical exception to the law governing serious offences against the person, many doctors and the lawyers they consulted doubted that this exception applied to gender reassignment surgery. In this article I trace the differing and changing interpretations of the medical exception as applied to gender reassignment surgery, and the shift towards legal acceptance in the two common law jurisdictions that led the way in both performing gender reassignment surgery and debating its legality, the United States and the United Kingdom. Although this shift occurred without formal legal intervention either through legislation or judicial decision (for example on a test case), inferences of legality drawn from related civil-law decisions bolstered the legal acceptance of gender reassignment surgery.By increasing the suffering of patients and potential patients, the criminal law played both an important and primarily malign role prior to the eventual public, professional and legal acceptance of GRS. A real threat of criminal prosecution inhibited doctors from proceeding, distorted diagnoses and affected the kinds of procedures performed. After-care was expanded and manipulated to avoid the risk of prosecution or the appearance of unlawful surgery. By contrast, civil and administrative law played a more positive, albeit indirect, role in interpreting the medical exception and its application to gender reassignment surgery.

U2 - 10.1093/ajlh/njx032

DO - 10.1093/ajlh/njx032

M3 - Article

SN - 0002-9319

JO - AMERICAN JOURNAL OF LEGAL HISTORY

JF - AMERICAN JOURNAL OF LEGAL HISTORY

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• The rise and fall of gende...

The rise and fall of gender identity clinics in the 1960s and 1970s

Editor’s note: this article is based on the second-place poster in the american college of surgeons history of surgery poster contest at the virtual clinical congress 2020. the authors note that as the field of medicine and society have evolved to better understand the experiences of transgender individuals, terminology has changed significantly. the authors have […].

Melanie Fritz, Nat Mulkey

April 1, 2021

Editor’s note: This article is based on the second-place poster in the American College of Surgeons History of Surgery poster contest at the virtual Clinical Congress 2020. The authors note that as the field of medicine and society have evolved to better understand the experiences of transgender individuals, terminology has changed significantly. The authors have kept the original wording of direct quotes, but elsewhere in the article terminology is used that is consistent with present-day standards; that is, “transgender” or “transgender and gender nonbinary.”

HIGHLIGHTS Summarizes early pioneering work in the GAS field in the U.S. and Europe Describes the effects of clinic closures in the 1970s Outlines the resurgence of multidisciplinary clinics for TGNB patients at academic centers and in private practice Identifies ongoing barriers related to GAS, including financial concerns and access to reliable information

Transgender and gender nonbinary (TGNB) individuals have existed for thousands of years and in cultures throughout the world. In Western medicine, however, the modern era of gender-affirming surgery (GAS) began at the Institute of Sexual Research in Berlin, Germany, under the leadership of Magnus Hirschfeld, MD. Surgeons at the institute performed the earliest vaginal constructions in the 1930s. Early patients included an employee of the facility, known by the last name of Dorchen, and the Danish painter Lili Elbe, whose story was depicted in the 2015 film The Danish Girl . 1

Around the same time that Dr. Hirschfeld’s institute began performing vaginoplasties, the father of plastic surgery, Sir Harold Gillies, OBE, FRCS, had been refining techniques for genital construction in Britain. He did so primarily by operating on British men who had sustained genital injuries during wartime and subsequently presented to him for assistance. In the 1940s, he performed the first known phalloplasty for a transgender patient on Michael Dillon, MD, a British physician. Dr. Gillies later performed a vaginoplasty on patient Roberta Cowell, who gained some renown in Britain. 2

In the 1950s, Georges Burou, MD, began performing vaginoplasty operations in Casablanca, Morocco, and is widely credited with inventing the anteriorly pedicled penile skin flap inversion vaginoplasty. 3

Increased awareness in the U.S.

One of the earliest known GAS procedures performed in the U.S. was for patient Alan Hart, MD, a transgender man and physician, who underwent a hysterectomy in 1910. 1

The field of GAS subsequently remained dormant in the U.S. until the 1950s, when pioneers like Elmer Belt, MD, University of California Los Angeles, and Milton Edgerton, MD, Johns Hopkins University (JHU) began performing GAS. 4,5

The work of sexologist and endocrinologist Harry Benjamin, MD, in the 1950s and 1960s provided additional momentum to the field within the medical community. At the time, many psychiatrists and physicians believed that the correct approach to treating transgender patients was exclusively through psychoanalytic therapy aimed at altering the desire to live as a different gender. Dr. Benjamin is attributed with being one of the first physicians to challenge this notion.

In 1966, he published The Transsexual Phenomenon , which detailed the era’s approach to GAS. 4 Notably, this text includes far more detail about male-to-female (MTF) surgical operations, such as vaginoplasty, than female-to-male (FTM) operations, such as phalloplasty or metoidioplasty. At the time, transgender men were incorrectly believed to be less common than transgender women, and surgeons were reluctant to perform FTM GAS procedures. Based on writings from the era, some of this reluctance stemmed from uncertainty as to whether surgical techniques were capable of constructing a neophallus that would be satisfactory to the patient. 6

A boom of awareness of GAS within both the field of medicine and the larger U.S. public can primarily be attributed to one individual: Christine Jorgensen. Ms. Jorgensen was a transgender woman who captured the attention and interest of the general public after undergoing a series of operations for GAS in Denmark from 1951 to 1952. 4 Her coming out story and transition were covered extensively in popular media, appearing in the New York Daily News under the eye-catching headline “Ex-GI Becomes Blonde Beauty.” 7

Wave of clinics providing GAS

Publication of Dr. Benjamin’s book coincided with the public announcement of JHU Gender Identity Clinic in November 1966. 8 While several major academic centers had internally discussed the formation of research institutes to study the treatment of transgender patients since the early 1960s, the opening of the JHU clinic marked a transition from quiet deliberation to public recruitment for research on GAS. Initiatives quickly sprung up at many major universities and hospitals, marked by interdisciplinary collaboration between psychiatrists, urologists, plastic surgeons, gynecologists, and social workers. While estimates vary, the increase in U.S. patients who underwent GAS was dramatic, growing to more than 1,000 by the end of the 1970s from approximately 100 patients in 1969. 5,9

Producing positive results in a stigmatized field

Whereas GAS was a new endeavor for U.S. physicians, these clinics primarily operated as research programs. As a new field of practice, the physicians involved in the clinics faced significant skepticism from colleagues, such as psychiatrist Joost Meerloo, MD, who outlined his concerns in the American Journal of Psychiatry in 1967. Dr. Meerloo wrote, “Unwittingly, many a physician does not treat the disease as such but treats, rather, the fantasy a patient develops about his disease…I believe the surgical treatment of transsexual yearnings easily falls into this trap…. What about our medical responsibility and ethics? Do we have to collaborate with the sexual delusions of our patients?” 10

Understandably, physicians involved in these gender identity clinics described feeling pressure to demonstrate successful postoperative outcomes in order to justify their work. In the introduction to a published case series on GAS, Norman Fisk, MD, a psychiatrist at Stanford University, CA, wrote, “In our efforts we were preoccupied with obtaining good results. This preoccupation, we believed, would enable us to continue our work in an area where many professional colleagues had, and retain, serious doubts as to the validity of gender reorientation.” 11

In an attempt to obtain good results, these clinics often maintained rigorous selection criteria that excluded a number of patients. The evaluation process required that patients undergo hormone treatment and live for a set period of time as the gender to which they intended to transition. This period of time could extend up to five years depending on the clinic, imposing a significant burden on patients. As one patient, transgender man Mario Martino, stated, “One talks of a period of two to five years. I agree that people should be tested. I think that they should be tested in every way possible before being accepted as a candidate for treatment. However, one of the problems that people tend to forget is that a female with a 48-inch bust cannot pass as a male for one day, much less for one year or five years, no matter how much he tries.” 12

Individuals who were considered traditionally attractive and were expected to be easily perceived as a member of the other sex, as well as individuals who were heterosexual per their gender identity, were considered better surgical candidates. To demonstrate the scale of this selectivity, out of 2,000 applications sent to JHU within two years of opening, only 24 patients underwent an operation. 5,11,13

Though early studies were small, many did, in fact, demonstrate successful psychiatric outcomes. A report from Edgerton and colleagues in 1970 found that at one to two years postoperatively, of nine patients who underwent GAS, all were glad to have undergone surgery, had greater self-confidence, and held “a brighter outlook for their future.” 5 When considering the competing demands of producing positive outcomes and providing GAS to patients in need, it’s clear how physicians working in these clinics were confronted with challenges in their roles. They were advocates for a marginalized population, and yet they also functioned as gatekeepers for thousands of transgender patients desperate for surgery and who faced reinforced gender-based stereotypes as described earlier in the eligibility criteria.

Timeline and clinic closure

Toward the end of the 1970s, many centers closed their doors to new patients. These closures often were kept out of the public eye, making it difficult to discern precise timing or causes. There were, however, two notable exceptions to the pattern of patient enrollment quietly declining and ceasing.

At JHU, a new chair of psychiatry, Paul McHugh, MD, was hired in 1975. Dr. McHugh disapproved of offering GAS to transgender patients and acknowledged that from the moment he was hired, he intended to stop this practice at the clinic. Under his leadership, JHU psychiatrist Jon Meyer, MD, published a study of 50 surgical patients from the JHU clinic, which concluded that GAS offered “no objective benefit” for transgender people. Although this claim directly contradicted a growing body of evidence that found significant benefit for transgender patients, the publication sparked the rapid closure of the JHU clinic in 1979. 14

FIGURE 1. GENDER IDENTITY CLINIC TIMELINE

Another gender identity clinic where operations were abruptly terminated was the Baptist Medical Center in Oklahoma City. The Gender Identity Foundation at the center had offered a variety of services for transgender patients, including GAS, since 1973, under the radar of local religious leaders. In 1977, however, the issue of GAS was brought to the attention of the board of directors of the Baptist General Convention of Oklahoma. The physicians involved fervently advocated to be allowed to continue their practice, including surgeons Charles L. Reynolds, Jr., MD, FACS, and David W. Foerster, MD, FACS, who issued a joint statement that said, “[I]f Jesus Christ were alive today, undoubtedly he would render help and comfort to the transsexual.” Despite these appeals, the board of directors voted 54–2 to ban GAS at the Baptist Medical Center. 15

Given the known timing of when these two clinics closed, they are marked with a box in a timeline constructed by the authors (see Figure 1). The remaining end dates are estimates derived from the latest reported operations in the medical literature and news articles, which likely underestimate the length of time the clinics were in operation. The reasons for closure of the remaining clinics appear to be multifactorial.

The publicity around the Meyer paper that led to JHU’s clinic closure may have played a role in the decision to close other clinics. 16 In addition, some clinics described financial challenges during this time, as patients often were unable to afford the expensive operations, and insurance companies refused to cover them. For example, at the University of Minnesota, Minneapolis, clinic, the first two dozen operations were funded by a research grant at the expense of the state, but a news article from 1972 suggests that funding difficulties were exacerbated when the state no longer wanted to fund the project. 9 Institutional pushback, such as that experienced at JHU, and the retirement of leading surgeons also may have played a role in the closure of gender identity clinics across the nation.

Even though many clinics’ GAS-related research was winding down in the late 1970s, the last 15 years of academic interest motivated the 1979 establishment of the Harry Benjamin International Gender Dysphoria Association. This organization, formed with the goal of organizing professionals who were “interested in the study and care of transexualism and gender dysphoria,” has since been renamed the World Professional Association for Transgender Health (WPATH) and has grown into an international interdisciplinary organization. 17 WPATH has established internationally accepted guidelines for treating individuals with gender dysphoria, which are periodically updated. The most recent of these guidelines is the Standards of Care Version 7 (SOC7). 18 Today, insurance companies, national payors, and treatment teams in both the U.S. and Europe use the WPATH SOC7 guidelines for establishing surgical eligibility.

Present day significance

The contemporaneous evolution of the first wave of gender identity clinics generated a rich field for refinement of surgical technique, as well as the assessment of postoperative outcomes, and produced a foundation of scientific literature demonstrating successful psychiatric outcomes for transgender people undergoing GAS. These milestones foreshadowed a resurgence of multidisciplinary clinics for TGNB individuals in academic centers and paved the way for private practitioners to specialize in GAS. For example, Stanley Biber, MD, a private practice surgeon in Colorado, performed more than 5,000 GAS operations during his 35 years in practice. 19

Many centers for transgender medicine and surgery now exist across the U.S., and the number of GAS operations being performed in the U.S. has increased substantially, along with expanded insurance coverage. In 2015, the U.S. Transgender Survey found that 25 percent of TGNB individuals had one or more gender-affirming operations. 20 Similar to the earlier wave of clinics, present-day clinics still are frequently composed of an interdisciplinary team of primary care, surgical, and mental health professionals.

Although the number of GAS continues to increase, the current discourse echoes earlier concerns about how to limit barriers for this marginalized population while prioritizing positive surgical outcomes. The WPATH standards of care often function as guides to assist health care centers in creating TGNB health programs. 21 The WPATH SOCs have evolved since their establishment and presently tend to include fewer preoperative requirements for TGNB patients than in the 1970s and 1980s.

However, TGNB patients continue to face significant barriers to accessing GAS. A 2018 survey of TGNB patients found that the most commonly cited barriers to gender-affirming care are financial concerns, access to physicians who are knowledgeable about GAS, and access to reliable information. 22 These financial concerns can be exacerbated by the cost of obtaining the mental health evaluations recommended by WPATH SOC7, and challenges associated with insurance coverage. 23 To address these barriers, institutions are considering preoperative models besides the WPATH SOC7 to potentially reduce challenges.

Moreover, general medical education initiatives are under way to increase provider knowledge about this population. 24,25 As the field of GAS continues to evolve in the present day, we look forward to seeing how the surgical and medical community partners with patients to minimize these barriers and promote access to these essential surgical treatments.

• Denny D. Gender reassignment surgeries in the XXth century. Workshop at 9th Transgender Lives: The Intersection of Health and Law Conference, Farmington, CT. May 10, 2015. Available at: http://dallasdenny.com/Writing/2015/05/10/gender-reassignment-surgeries-in-the-xxth-century-2015/ . Accessed February 11, 2021.
• Kennedy P. The First Man-Made Man: The Story of Two Sex Changes, One Love Affair, and a Twentieth-Century Medical Revolution . New York: Bloomsbury USA; 2007.
• Hage JJ, Kareem RB, Laub DR. On the origin of pedicled skin inversion vaginoplasty: Life and work of Dr. Georges Burou of Casablanca. Ann Plast Surg . 2007;59(6):723-729.
• Benjamin H. The Transsexual Phenomenon . New York, New York: Warner Books Incorporated; 1966.
• Edgerton MT, Knorr NJ, Callison JR. The surgical treatment of transsexual patients. Limitations and indications. Plast Reconstr Surg . 1970;45(1):38-46.
• Williams G. An approach to transsexual surgery. Nurs Times . 1973;69(25):787.
• Ex-GI becomes blonde beauty: Operations transform Bronx youth. New York Daily News . December 1, 1952:75. Available at: www.newspapers.com/clip/25375703/ex-gi-becomes-blonde-beauty/ . Accessed March 22, 2021.
• Buckley T. A changing of sex by surgery begun at Johns Hopkins. The New York Times . November 21, 1966. Available at: www.nytimes.com/1966/11/21/archives/a-changing-of-sex-by-surgery-begun-at-johns-hopkins-johns-hopkins.html . Accessed March 22, 2021.
• Brody J. 500 in the U.S. change sex in six years with surgery. The New York Times . Nov 20, 1972. Available at: www.nytimes.com/1972/11/20/archives/500-in-the-u-s-change-sex-in-six-years-with-surgery-500-change-sex.html . Accessed February 11, 2021.
• Meerloo JA. Change of sex and collaboration with the psychosis. Am J Psychiatry . 1967;124(2):263-264.
• Fisk NM. Five spectacular results. Arch Sex Behav . 1978;7(4):351-369.
• Money J. Transsexualism: Open forum. Arch Sex Behav . 1978;7(4):387-415.
• Hastings D, Markland C. Post-surgical adjustment of 25 transsexuals at University of Minnesota. Arch Sex Behav . 1978;7(4):327-336.
• Siotos C, Neira PM, Lau BD, et al. Origins of gender affirmation surgery: The history of the first gender identity clinic in the United States at Johns Hopkins. Ann Plast Surg . 2019;83(2):132-136.
• Baptists vote to ban sex change operations. Sarasota Herald-Tribune . October 15, 1977.
• Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins. Washington Post . April 5, 2017. Available at: www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.html . Accessed February 11, 2021.
• Walker PA. The University of Texas Medical Branch. Memo to persons interested in the Harry Benjamin International Gender Dysphoria Association. April 17, 1979. Available at: www.wpath.org/media/cms/Documents/History/Harry%20Benjamin/First%20HBIGDA%20Membership%20Request%20Letter%201979.pdf . Accessed February 11, 2021.
• Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend . 2012;13(4):165-232.
• Arrillaga P. Onetime coal mining town bolstered by changing economy. Los Angeles Times . June 4, 2000. Available at: www.latimes.com/archives/la-xpm-2000-jun-04-me-37512-story.html . Accessed February 11, 2021.
• James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 Transgender Survey. Washington, DC: National Center for Healthcare Equality, 2016. Available at: www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF . Accessed February 11, 2021.
• National LGBT Health Education Center. Creating a transgender health program at your health center: Planning to implementation. September 2018. Available at: www.lgbtqiahealtheducation.org/wp-content/uploads/2018/10/Creating-a-Transgender-Health-Program.pdf . Accessed February 11, 2021.
• El-Hadi H, Stone J, Temple-Oberle C, Harrop AR. Gender-affirming surgery for transgender individuals: Perceived satisfaction and barriers to care. Plast Surg . 2018;26(4):263-268.
• Puckett JA, Cleary P, Rossman K, Newcomb ME, Mustanski B. Barriers to gender-affirming care for transgender and gender nonconforming individuals. Sex Res Social Policy . 2018;15(1):48-59.
• Lichtenstein M, Stein L, Connolly E, et al. The Mount Sinai patient-centered preoperative criteria meant to optimize outcomes are less of a barrier to care than WPATH SOC 7 criteria before transgender-specific surgery. Transgend Health . 2020;5(3):166-172.
• Streed CG, Davis JA. Improving clinical education and training on sexual and gender minority health. Curr Sex Health Rep . 2018;10:273-280.

Origins of Gender Affirmation Surgery: The History of the First Gender Identity Clinic in the United States at Johns Hopkins

Affiliation.

• 1 Office of Diversity and Inclusion, Johns Hopkins Medical Institutions, Baltimore, MD.
• PMID: 30557186
• DOI: 10.1097/SAP.0000000000001684

Background: Gender-affirming care, including surgery, has gained more attention recently as third-party payers increasingly recognize that care to address gender dysphoria is medically necessary. As more patients are covered by insurance, they become able to access care, and transgender cultural competence is becoming recognized as a consideration for health care providers. A growing number of academic medical institutions are beginning to offer focused gender-affirming medical and surgical care. In 2017, Johns Hopkins Medicine launched its new Center for Transgender Health. In this context, history and its lessons are important to consider. We sought to evaluate the operation of the first multidisciplinary Gender Identity Clinic in the United States at the Johns Hopkins Hospital, which helped pioneer what was then called "sex reassignment surgery."

Methods: We evaluated the records of the medical archives of the Johns Hopkins University.

Results: We report data on the beginning, aim, process, outcomes of the clinic, and the reasons behind its closure. This work reveals the function of, and the successes and challenges faced by, this pioneering clinic based on the official records of the hospital and mail correspondence among the founders of the clinic.

Conclusion: This is the first study that highlights the role of the Gender Identity Clinic in establishing gender affirmation surgery and reveals the reasons of its closure.

Publication types

• Historical Article
• Gender Dysphoria / epidemiology
• Gender Dysphoria / surgery*
• History, 20th Century
• History, 21st Century
• Hospitals / history*
• Sex Reassignment Surgery / history*
• United States / epidemiology

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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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JK Rowling's remarks on transwoman spark row: 'Calling a man a man not bullying'

The harry potter novelist has been accused of cruelty for mocking the world's first openly transgender football manager by calling her a "straight, white, middle-aged bloke"..

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• JK Rowling criticised for remarks on transgender football manager
• Rowling's comments sparked outrage on social media
• Rowling defended herself stating calling a man a man is not 'bullying'

Renowned author JK Rowling has found herself embroiled in controversy yet again, this time accused of insensitivity for her comments regarding the world's first openly transgender football manager, Lucy Clark.

The Harry Potter novelist came under fire after responding to a post by LGBTQ+ charity Pride on X (formerly known as Twitter) , celebrating Clark's achievements.

The transgender referee recently made history by becoming the first manager in the top five divisions of English Women's football, who identifies as a transwoman.

When I was young all the football managers were straight, white, middle-aged blokes, so it's fantastic to see how much things have changed. https://t.co/jx9zp0hRyU — J.K. Rowling (@jk_rowling) May 11, 2024

Rowling's response to the post stirred up outrage, with many social media users condemning her remarks as cruel.

Pride's original post featured a photo of Clark proudly brandishing her pink whistle and a red card, her dark brown hair cascading in waves around her shoulders.

Reacting to the social media backlash, the Cormoran Strike author said that calling a man a man is not 'bullying' or 'punching down'. Rowling also said that she did not compare the football manager to a "straight, white, middle-aged bloke", but that "he IS one".

"I didn’t compare him to one. He IS one," Rowling said in a tweet.

Calling a man a man is not 'bullying' or 'punching down.' Crossdressing straight men are currently one of the most pandered-to demographics in existence, and women are under no obligation to applaud the people caricaturing us. — J.K. Rowling (@jk_rowling) May 12, 2024

Earlier in March, Rowling sparked another controversy after she shared a message on Mother's Day seemingly trolling trans activists and inclusive language.

"Happy Birthing Parent Day to all whose large gametes were fertilised resulting in small humans whose sex was assigned by doctors making mostly lucky guesses," Rowling had said.

The UK’s New Study on Gender Affirming Care Misses the Mark in So Many Ways

It’s like the desantis administration wrote it..

Henry Carnell

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Protesters gathered in August 2021 outside the office of the Prime Minister demanding an end to discrimination against the trans community in the United Kingdom. Vuk Valcic / ZUMA

Last month, the UK’s four-year-long review of medical interventions for transgender youth was published . The   Cass Review, named after Hilary Cass, a retired pediatrician appointed by the National Health Service to lead the effort, found that “there is not a reliable evidence base” for gender-affirming medicine. As a result, the report concludes, trans minors should generally not be able to access hormone blockers or hormone replacement therapy (HRT) and instead should seek psychotherapy. While the review does not ban trans medical care, it comes concurrently with the NHS heavily restricting puberty blockers for trans youth.

The conclusions of the Cass Review differ from mainstream standards of care in the United States, which recommend medical interventions like blockers and HRT under certain circumstances and are informed by dozens of studies and backed by leading medical associations . The Cass Review won’t have an immediate impact on how gender medicine is practiced in the United States, but both Europe’s “gender critical” movement and the anti-trans movement here in the US cited the report as a win, claiming it is the proof they need to limit medical care for trans youth globally. Notable anti-trans group the Society for Evidence Based Gender Medicine called the report “a historic document the significance of which cannot be overstated,” and argued that “it now appears indisputable that the arc of history has bent in the direction of reversal of gender-affirming care worldwide.”

Most media coverage of the report has been positive. But by and large that coverage has failed to examine extensive critiques from experts in the US and elsewhere. Research and clinical experts I interviewed explained that the Cass Review has several shortcomings that call into question many of its findings, especially around the quality of research on gender medicine. They also question the credibility and bias underpinning the review. I spoke with four clinical and research experts in pediatric medicine for gender-diverse youth to dive into the criticisms.

“I urge readers of the Cass Review to exercise caution,” said Dr. Jack Turban, director of the gender psychiatry program at the University of California, San Francisco and author of the forthcoming book Free to Be: Understanding Kids & Gender Identity .  

The Cass Report’s bar for evaluating research is too high

In scientific research, the randomized control trial (RCT) is often considered the gold standard. In a randomized control trial, study subjects are randomly split up into two groups. One group gets the treatment being examined. The other group doesn’t, and is used as a baseline with which compare the effects of the treatment.

But there are ethical limits to this setup, says Dr. Meredithe McNamara, a professor of pediatrics at Yale School of Medicine who co-leads the Integrity Project , a Yale research hub meant to bridge the gap between policy and science. RCT’s are great when “it is not known whether or not the intervention might be beneficial,” McNamara says. “Having pre-knowledge of benefits means that we would never consider randomizing somebody to no treatment.” In other words, RCTs are a great option when there is not a lot of data pointing to the efficacy of a certain drug or treatment program. But when that data does exist, using RCTS would be considered “unethical” and “coercive,” says McNamara.

In the case of gender-affirming care, decades of research exists showing “gender-affirming care confers key benefits to those who desire and qualify for this care, including youth,” McNamara explains. “It would not make sense ethically to conduct a randomized control trial.” The Federal Drug Administration suggested as much last year, when it told researchers conducting a study on estrogen for trans patients not to use an RCT. That clinical study may include youth as young as 13, per suggestion from the FDA.

The evidence supporting medical interventions for trans youth comes from primarily observational studies, meaning those conducting the research collected data on people undergoing gender-affirming medical care. These kinds of studies are used 70 percent of the time in research on health care, McNamara explains. Alex Keuroghlian, an associate professor of psychiatry at Harvard Medical School and a clinic psychiatrist and director of education at Fenway Health in Boston, emphasizes that gender-medicine providers are not making choices arbitrarily or without robust research. “It’s really setting a double standard in terms of expectations for evidence supporting medical intervention. It is not the standard we expect in other contexts,” they say.

Cass’ systematic evidence reviews used the “somewhat subjective”—as Turban puts it—Newcastle-Ottawa scale rating system to evaluate research on gender-affirming care, which is a rating system to evaluate observational studies. (More precisely, the review actually commissioned researchers at the University of York to conduct the ratings, which Cass then discusses at length in her own report).

The reviewers from York evaluated the research on a scale from “low quality” to “high quality” and found that “much of the research rated as moderate or even sometimes high quality,” explains Turban. But the Cass Review diverged from these findings. Some experts suspect that may be because she compared the research to RCTs despite their inappropriateness. There is “actually wider understanding of the evidence than the Cass Review presents,” says Streed. Cass categorically denies that the review “set a higher bar for evidence than would normally be expected.”

“It’s a bad faith claim that we don’t have enough evidence for pubertal suppressants or gender-affirming hormones,” says Keuroghlian, who has worked with over 2,000 trans and gender-diverse patients in their career. “Gender-affirming medical interventions have been used for adolescent gender dysphoria for decades, and we have a large body of evidence linking them to improved mental health outcomes,” says Turban.

Cass doesn’t apply important terminology consistently or accurately

Multiple experts told me that the language in the review diverged from technical standards and may confuse readers. McNamara explains: “There is a lot of terminology-switching throughout the report.” “Low-quality evidence” is a technical term with specific technical meanings that can be interpreted by researchers, she says. “Weak” or “poor quality,” on the other hand, are “subjective terms that might strike a chord with the lay public but don’t have any concrete meaning.” This means that a reader who is not an expert in medical research may assume that the there are dangers or uncertainties around this health care when there are not. 

Perhaps because of the loose use of terminology, the Cass report describes some gender-medicine research as “poor” even though those same studies were rated “moderate” or “high quality” by reviewers at the University of York. The studies downgraded by Cass all demonstrated the efficacy of gender-affirming medical interventions. On the other hand, other studies that didn’t come to such strong conclusions in favor of intervention were not similarly downgraded. 

Carl Streed, the research lead for the GenderCare Center at Boston Medical Center and president of the US Professional Association for Transgender Health, clarifies that just because a study is classified as “low-quality” in the report does not mean the data is not robust or rigorous. “It doesn’t actually mean the evidence itself is not to be trusted,” he explains. “It is just that you have to understand the nuance of the methods to understand the context of the results.” 

Cass endorses questionable therapeutic treatment  

The Cass review recommends psychotherapy as the main and frontline treatment for gender-diverse youth, in place of medical interventions like puberty blockers. But the experts I spoke to say the evidence shows psychotherapy alone doesn’t do enough. Clinicians have been trying “psychotherapy as the way to solve issues around gender since at least the late 1800s” explains Streed. “It wasn’t working. It wasn’t leading to any kind of significant success, people still had significant distress.” 

“No contemporary evidence whatsoever shows that people who receive only psychotherapy experience improvements in gender dysphoria,” says McNamara. “There is an abundance of evidence showing that medically affirming interventions confer key benefits and there is none regarding psychotherapy alone.”

What’s more, the therapeutic approach Cass seems to suggests has close ties to conversion therapy. While Cass does not recommend a specific modality, she repeatedly advocates for an “exploratory” approach. She writes: “The intent of psychological intervention is not to change the person’s perception of who they are but to work with them to explore their concerns and experiences and to help alleviate distress.” 

Fair enough. Except that these are the same talking points that conversion therapists use to describe their work. There’s even a group, Therapy First, devoted to pushing the idea of “gender exploratory therapy.” Therapy First’s co-founder has advocated to make conversion therapy bans more lenient to make room for an “exploratory” approach. The US Substance Abuse and Mental Health Services Administration has stated that gender change efforts are often “misleadingly referred to as ‘exploratory therapy.’” 

Streed explains that “at best, gender exploratory therapy is just delaying people’s access to the care they need, and at worst, it is conversion therapy. That is what we’ve seen in multiple studies, and it is associated with harm.” Keuroghlian puts it more bluntly: “Not providing gender affirming care in a timely way” is “trafficking in conversion efforts.” 

“It feels like a double standard to say, ‘Oh, there’s no evidence for medical and surgical interventions with regards to gender-affirming care or affirmation,’ but then, ‘Oh, let’s turn around and offer this other therapy that has absolutely no evidence,’” says Streed.

In a follow-up Q&A, Cass said she “believes that no LGBTQ+ group should be subjected to conversion practice.” At the same time, she stands behind her inclusion of exploratory therapies, saying, “young people with gender dysphoria may have a range of complex psychosocial challenges and/or mental health problems impacting on their gender-related distress. Exploration of these issues is essential.”

The Cass Report shows signs of bias 

Cass does a fair amount of work at the outset of the report to make clear that she’s not attempting to undermine “the validity of trans identities” or rollback “people’s rights to healthcare.”

But Cass goes too far in her attempts to remain neutral. The review cites sources that lack credibility or are from anti-trans actors, including an article written a college undergraduate, a pamphlet funded by an anti-trans group, and a YouTube channel run by right-wing commentators. More than once she cites notable exploratory therapists like Ken Zucker.

Further, experts note the report does not disclose all the people who collaborated on the project and their affiliations. Streed says, for similar reviews, “every author has to have their name on it and say what their conflicts of interests are, where they are getting their funding from. The Cass Report does not offer that information. For me, that is a big red flag.” Some of those connections have become clearer since the report was published. For example, the blog Growing Up Transgender   uncovered  a 2022 meeting between the US Department of Health and Human Services and the Society for Evidence-Based Gender Medicine, which the Southern Poverty Law Center has dubbed “the hub” of the “anti-LGBT pseudoscience network.”  Representing SEGM were Richard Byng and R. Stephens, who were identified in the meeting as part of NHS’ “working group on Gender Dysphoria.” 

More broadly, Keuroghlian and McNamara both argue that Cass’ conclusions undermining the observational studies is itself a form of bias. “The review’s conclusions are discriminatory,” says Keuroghlian. “It’s an intentional misapplication of science to deny a minoritized group access to medically necessary evidence-based care.” “Any deviation from basic principles of evidence-based medicine suggests bias,” says McNamara. 

Allegations of bias in the report are not new. In November 2023, Zinnia Jones, who runs the website and web series Gender Analysis , surfaced court documents in GLAD’s constitutional challenge to Florida’s ban on gender-affirming care for youth. The documentation showed that in 2022, Cass met with Patrick Hunter, a DeSantis appointee to the Florida Board of Medicine, member of SEGM, and big proponent of banning gender affirming medical care for transgender youth.

Hunter sent Cass materials from Florida’s thoroughly discredited 2022 review of gender medicine. That review had gotten edits from Andre Van Mol, a member of a fringe, conservative doctors group that calls itself the American College of Pediatricians (ACPeds). (Read more about Van Mol and his partners in my colleague Madison Pauly’s investigation .) Cass passed along research from her in-progress review and was even invited to do a presentation in front of the Florida Board of Medicine, which was then putting together specific regulations on youth access to HRT and puberty blockers. The Florida review and Cass reports draw similar conclusions about the “weak” research on gender-affirming care. 

The experts I spoke to hope the report is not set in stone. “This report and its systematic reviews were just released, and experts are actively reviewing their contents,” Turban says. “Our team has already identified an error with the systematic review on gender-affirming hormones and has notified the journal, requesting a correction be issued.” 

“There are no neutral decisions to be made for transgender youth.” McNamara explains, “We have to recognize that physical change that does not align with a person’s gender identity is a source of harm for people who experience gender diversity and dysphoria. Simply watching that happen, feel feels like doing harm.”

Correction: An earlier version of this story misstated the relationship between the Newcastle-Ottawa scale and RCTs. 

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BAFTA Awards trouble as medics rush to MAFS star struggling in the heat

A Married At First Sight UK reality star was seen to by a medic after arriving at tonight's BAFTA TV Awards ceremony

• 17:06, 12 May 2024
• Updated 17:33, 12 May 2024

A medic was seen tending to a Married At First Sight UK star after they arrived on the red carpet for tonight's BAFTA TV Awards ceremony.

Reality star Ella Morgan, who rose to fame on the E4 programme last year, rocked a black corsetted dress for the event but was seen slumping over when she got to the end of the red carpet, which worried her co-stars. Temperatures on Sunday afternoon hit 26 degrees Celsius, which affected the stars.

In pictures shared online, Ella chatted to the medic as she sat down near the railing at the Royal Festival Hall in London. The star helped fill out a form the medic was holding onto and seemed to be feeling better after getting some needed rest as she hid away from the sun.

“The cast and crew from Channel 4 grabbed hold of her and helped her stay on her feet before it was decided to call in the medics," one witness commented on the situation at the festival hall. "An area was cleared at the end and Bafta crews sent medics to assess Ella.”

They added to The Sun : "The crew rallied around her to create shade from the sun while she was being evaluated." Ella found fame when she appeared in the previous series of Married At First Sight UK. She originally coupled up with Nathanial Valentino but ended up falling for JJ Slater, who was in a different marriage.

A lot of drama transpired in the series, with the star and JJ choosing to remain as friends at the final vows. Last month, Ella took to social media to open up about the cosmetic procedures she underwent. The star is transgender and revealed all the procedures she has undergone in recent years in an honest discussion on Instagram .

Sharing a picture of herself in which her eyes are a deep shade of purple and she is wearing a nose splint, Ella told her followers all the operations she has endured as she listed the procedures. Captioning the startling photo, she said: "I've had botox and fillers obvs, but these are the surgical procedures and before anyone pops off, I have transitioned, so there was a lot I wanted to change on the outside."

Ella continued: "GRS - gender reassignment surgery, vaginoplasty (the downstairs area basically), two boob jobs, nose job, lip lift, hairline lowering, brow bone and forehead shave, brow lift, temple implant, Adam's apple shave, mole removal, fat injected into cheek and under eyes."

The Mirror have contacted her reps for comment.

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BAFTAs medics rush to treat Channel 4 star struggling with heat on red carpet

Married at first sight uk star ella morgan was seen being treated by medics at the bafta tv awards after she was overcome by the heat in a stunning black gown.

BAFTA TV Awards plunged into disarray as medics dash to aid ailing MAFS star Ella Morgan amid scorching temperatures. The reality TV favourite, known for her appearance on Married at First Sight UK , was in dire need of medical attention after succumbing to the heat during the glamorous event.

Dressed to impress in an exquisite black corseted dress, Ella unfortunately found herself overwhelmed by the blistering 26-degree heat on the red carpet. Concerns escalated quickly among her reality show peers when she appeared to wobble towards the end of the red carpet procession.

Images now making the rounds on the internet depict Ella being attended to by a medic while seated near the barriers outside the Royal Festival Hall in London.

Ella was seen completing forms with the medic and seemed to recover somewhat after resting in a cooler spot. A witness recounted: "The cast and crew from Channel 4 grabbed hold of her and helped her stay on her feet before it was decided to call in the medics," as reported by the Mirror.

Relaying the incident to The Sun, they added: "The crew rallied around her to create shade from the sun while she was being evaluated.", reports the Daily Star .

READ MORE Alex Scott showcases figure in another see-through dress for racy BAFTAs look

Ella gained notoriety on the most recent season of Married At First Sight UK, where she was initially matched with Nathanial Valentino but later developed feelings for JJ Slater, who had been paired with another contestant.

The series was rife with drama, culminating in Ella and JJ choosing to remain friends after their final vows. Recently, Ella took to her social media platforms to divulge details about her journey with cosmetic enhancements.

Don't miss... BAFTAs 2024 LIVE - All the best moments and winners announced [UPDATE] BAFTAs 2024 - Black dominates the red carpet as stars attend awards ceremony [INSIGHT ] TV BAFTA PREVIEW - Hannah Waddingham and Baroness Benjamin tipped for big nig... [LATEST]

The transgender trailblazer revealed her complete portfolio of surgical procedures during an honest discussion with her Instagram followers.

Sharing a striking image, showing her eyes marked with vivid purple spots and her nose covered with a splint, Ella detailed her ongoing journey through surgery, as she recounted her transformation story.

Against the backdrop of the bold photo, she wrote: "I've had botox and fillers obvs, but these are the surgical procedures and before anyone pops off, I have transitioned, so there was a lot I wanted to change on the outside."

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Ella left no stone unturned as she shared: "GRS - gender reassignment surgery, vaginoplasty (the downstairs area basically), two boob jobs, nose job, lip lift, hairline lowering, brow bone and forehead shave, brow lift, temple implant, Adam's apple shave, mole removal, fat injected into the cheek and under eyes."

The BAFTAs 2024 ceremony airs on BBC One between 7pm and 9pm tonight.

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• Lorraine Kelly savagely slammed by GMB viewers as interview sparks backlash
• ITV's Lorraine Kelly vows to 'never retire' even if her show is axed
• Romesh Ranganathan and Rob Beckett 'relieved' at BAFTA return after near-brawl

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Cannes Film Festival 2024: the five films to look out for

From francis ford coppola’s self-funded comeback to kevin costner’s sweeping western, here are the films you need to know about.

T he Cannes Film Festival is not quite what it used to be. Yes, it still premieres movies — down on the Côte d’Azur during a chaotic fortnight when bedraggled industry folk stare out enviously at the anchored yachts of the super-rich. However, where the festival used to be all about arthouse offerings, discovering a debut Romanian gem and amplifying it for audiences back home, over the years Hollywood has co-opted the market. Last year, for instance, Indiana Jones and the Dial of Destiny created the most headlines, and it is absolutely certain that a derided sequel to an ancient blockbuster is not what Cannes was founded for in 1939.

Look beyond the glitz and studio cash, though, and the festival still offers gems. Last year

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UK toddler has hearing restored in world first gene therapy trial

Opal Sandy can hear almost perfectly after groundbreaking surgery that took just 16 minutes

A British toddler has had her hearing restored after becoming the first person in the world to take part in a pioneering gene therapy trial, in a development that doctors say marks a new era in treating deafness.

Opal Sandy was born unable to hear anything due to auditory neuropathy, a condition that disrupts nerve impulses travelling from the inner ear to the brain and can be caused by a faulty gene.

But after receiving an infusion containing a working copy of the gene during groundbreaking surgery that took just 16 minutes, the 18-month-old can hear almost perfectly and enjoys playing with toy drums.

Her parents were left “gobsmacked” when they realised she could hear for the first time after the treatment. “I couldn’t really believe it,” Opal’s mother, Jo Sandy, said. “It was … bonkers.”

The girl, from Oxfordshire, was treated at Addenbrooke’s hospital, part of Cambridge university hospitals NHS foundation trust, which is running the Chord trial . More deaf children from the UK, Spain and the US are being recruited to the trial and will all be followed up for five years.

Prof Manohar Bance, an ear surgeon at the trust and chief investigator for the trial, said the initial results were “better than I hoped or expected” and could cure patients with this type of deafness.

“We have results from [Opal] which are very spectacular – so close to normal hearing restoration. So we do hope it could be a potential cure.”

He added: “There’s been so much work, decades of work … to finally see something that actually worked in humans …. It was quite spectacular and a bit awe-inspiring really. It felt very special.”

Auditory neuropathy can be caused by a fault in the OTOF gene, which makes a protein called otoferlin. This enables cells in the ear to communicate with the hearing nerve. To overcome the fault, the new therapy from biotech firm Regeneron sends a working copy of the gene to the ear.

A second child has also recently received the gene therapy treatment at Cambridge university hospitals, with positive results.

The overall Chord trial consists of three parts, with three deaf children including Opal receiving a low dose of gene therapy in one ear only.

A different set of three children will get a high dose on one side. Then, if that is shown to be safe, more children will receive a dose in both ears at the same time. In total, 18 children worldwide will be recruited to the trial.

Opal is the first patient globally to receive the therapy and is “the youngest globally that’s been done to date as far as we know”, Bance said.

The gene therapy – DB-OTO – is specifically for children with OTOF mutations. A harmless virus is used to carry the working gene into the patient.

The trial is “just the beginning of gene therapies”, Bance said. “It marks a new era in the treatment for deafness.”

Martin McLean, a senior policy adviser at the National Deaf Children’s Society, said deafness should never be a barrier to happiness or fulfilment. “Many families will welcome these developments, and we look forward to learning about the long-term outcomes for the children treated.”

With Opal’s hearing restored, her parents now have a fresh problem to contend with: their daughter’s new favourite hobby is slamming cutlery on the table to make as much noise as possible.

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Deaf toddler playing piano and dancing after world-first gene therapy

Opal Sandy, an 18-month-old from Oxfordshire, had ‘spectacular’ results after surgery during international trial

A deaf toddler is now able to hear after becoming the first patient in the world to receive a new gene therapy .

Opal Sandy, an 18-month-old girl from Oxfordshire, was born with a genetic form of a condition called auditory neuropathy, which disrupts nerve impulses travelling from the inner ear to the brain and prevents sound being processed.

In September, she became the first person in the world to receive gene replacement treatment as part of a global trial, and experts are excited by the “potential cure” for the condition.

Opal, like her five-year-old sister Nora, was born with a faulty version of the OTOF gene, which carries the instructions for a neurotransmitter to be produced that allows the ear to communicate with the brain. The malfunction causes severe hearing loss.

Nora’s diagnosis meant Opal was eligible for genetic testing on the NHS, which detected she also had the faulty gene. The condition had not been picked up by newborn screening tests in either child.

While Nora has cochlear implants in both ears, which are the current gold-standard treatment, Opal was able to join the gene therapy trial, although she also has an implant in one ear as a safety measure.

The gene therapy, called DB-OTO and manufactured by Regeneron, works by replacing the faulty gene with a working version. It is administered by a single injection of a modified and harmless virus carrying the new genetic material.

The treatment means the ear’s sensory cells are able to produce a vital protein called otoferlin that is required for the tiny hair cells in the ear to transmit signals to the brain.

Opal’s parents, Jo and James Sandy, noticed improvements after just three weeks and things have only improved since. Opal’s doctors say her hearing is now “almost normal for her age” although progress will become clearer as she learns to talk.

Ms Sandy, a 33-year-old geography teacher, said it was “bonkers” how quickly her daughter became able to hear.

She videoed her daughter responding to the sound for the first time.

The parents had become accustom to trying to get Opal’s attention by making loud noise from behind her back but to little avail.

Until one day she turned to the sound of her mother clapping as she played.

“We were in the routine of testing quite loud sounds like banging, clapping, wooden spoons on saucepans, that kind of really intermittent loud noise,” she said.

“I was testing that with her implant on and hadn’t realised that her implant had actually come off, and she turned to pretty loud clapping. When she first turned, I couldn’t believe it.

“I thought it was a fluke or like a change in light or something that had caught her eye, but I repeated it a few times. I was absolutely gobsmacked.”

Opal, who had her surgery at Addenbrooke’s Hospital in Cambridge, is one of up to 18 children due to be enrolled on the trial, which is taking place in the UK, US and Spain.

While Opal received a low dose to one ear, others will be given higher doses to the other ear, before some children receive the treatment in both ears once there is more evidence it is safe.

Prof Manohar Bance, an ear surgeon at Cambridge University Hospitals NHS Foundation Trust, which runs Addenbrooke’s, and the trial’s chief investigator, said the results were “better than I hoped or expected” after 24 weeks.

“We have results from [Opal] which are very spectacular – so close to normal hearing restoration. So we do hope it could be a potential cure.

“In terms of being able to hear soft sounds (like a soft whisper), she can hear almost normal for her age,” he said. “We don’t know that she can understand speech in the same way because she’s too young, but certainly she can respond to soft sounds.”

A second child has also received the gene therapy treatment at Cambridge University Hospitals, with positive results seen recently, six weeks after surgery, while other gene therapies for deafness are being trialled in China and the US.

Prof Bance estimates that around 20,000 people in the US, Germany, France, Italy, Spain and the UK have auditory neuropathy resulting from OTOF mutations.

Martin McLean, the senior policy adviser at the National Deaf Children’s Society, said: “This trial will teach us more about the effectiveness of gene therapy in those cases where deafness has a specific genetic cause.

“We would like to emphasise that, with the right support from the start, deafness should never be a barrier to happiness or fulfilment.”

Sisters ‘compete to make most noise’

Mrs Sandy said Opal had started to talk in the last six weeks and now both her daughters like “seeing who can make the most noise”.

“She’s good at all your common first baby words, so ‘daddy’ is a favourite, ‘uh oh’, ‘bye bye’,” she said.

“I always said I’d never get annoyed with them making noise and I do get annoyed with them making noise,” Mrs Sandy joked.

“Opal loves playing with her little musical instrument set ... playing the drums, playing her little piano, tapping some of her wooden blocks and things like that.

“Nora got into music quite recently and [Opal] likes to put her arms up and does little dances in the kitchen.

“So they like dancing together. Nora likes reading to her, they like fighting, they like jumping off the sofa.”

The results from the Chord trial were presented on Wednesday to the American Society of Gene and Cell Therapy conference in Baltimore in the US.

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