番茄社区

When the Gender Identity Clinic (GIC) at Baltimore's Johns Hopkins Hospital closed in 1979, there were still about 20 university-based clinics in the U.S. that provided gender-affirming surgery. By the mid-1990s, only two or three remained.

Despite the hospital attributing the closure of GIC to suggesting unsatisfactory long-term outcomes among 50 applicants for gender-affirming surgery, Walker Magrath, a third-year medical student at Johns Hopkins University School of Medicine, revealed evidence that political, social, and financial interests pushed the first-of-its-kind clinic into a tiny space and depleted its resources, which ultimately led to its closure.

In a "History of Medicine" piece published in the , Magrath wrote that Johns Hopkins' "original narrative that the decision to end [gender-affirming surgery] was based on science alone" is incomplete.

"Why would an institution be doing the surgery for over a decade, 13 years, be the first institution in the country to do it, and then just suddenly shut its doors?" said Magrath in an interview with 番茄社区. "I wanted to see what kind of role non-scientific factors had in the closure of this clinic because I sensed that there was more to the picture."

"When Johns Hopkins' GIC opened the doors to gender-affirming surgery, suddenly there was this mainstream sort of legitimacy to gender affirmation that hadn't been granted to it yet," Magrath noted. When the clinic ultimately closed, "it had a huge impact ... all of these other clinics across the country were thinking about closing too, and eventually did close."

In an , Alex S. Keuroghlian, MD, MPH, of Harvard Medical School and Massachusetts General Hospital in Boston, and Asa E. Radix, MD, PhD, of the NYU Grossman School of Medicine, noted that "the GIC's closure in 1979 was a canary in the coal mine for reverberating shutdowns of gender-affirming care practices across the United States soon thereafter."

"Decades later, this cycle has resumed, with politicization of science, intimidation tactics, threat campaigns, and government directives successfully halting the provision of medically necessary care for TGD [transgender and gender-diverse] persons -- particularly youth -- in desperately underserved regions of the country," they wrote.

The closure "became like a battle cry for the conservatives, like, 'Oh, this esteemed medical institution isn't doing these surgeries anymore; therefore, we shouldn't do them at all,'" Magrath said, adding that scientific "evidence" is still harnessed today by politicians in efforts to roll back gender-affirming care.

One example is the opinion from Texas Attorney General Ken Paxton, which was used as the basis for Texas Governor Greg Abbott's directive to investigate gender-affirming therapy as child abuse. In a report called "," a group from Yale University wrote that the opinion "misunderstands or deliberately misstates medical protocols and scientific evidence."

History of GIC

John Hoopes, MD, a plastic surgeon and the inaugural director of Johns Hopkins' GIC, initially saw genitourinary reconstruction on transgender patients as an opportunity to further his own field. By the mid-1970s, however, plastic surgery had gained more recognition, and Hoopes' priorities shifted.

He increasingly viewed and wrote about transgender people using disparaging and de-legitimizing terms. He even admitted in a 1978 letter to the chairperson of the GIC that his discontinuation of participating in the GIC "was taken partially, perhaps, on the basis of personal bias, but largely on the basis of long-term clinical data regarding the efficacy of surgical procedures," adding "I wish to request that [these] operative procedures ... not be performed under the auspices of the Division of Plastic Surgery."

He also encouraged Jon K. Meyer, MD, who co-authored the study that dealt the death blow to the clinic, to write a "strongly worded paper outlining our reasons for no longer participating in ... the performance of transsexual surgery."

The GIC was subsequently pushed into the existing Women's Clinic, which housed the ob/gyn department of the hospital, and was "so outdated that some patients refused to go there," according to one Baltimore Sun article. Attention around the recall of one of the first intrauterine device prototypes, called the Dalkon Shield, further drew unwelcome publicity to the ob/gyn department.

While the clinic was on the defensive, one of its biggest advocates, sexologist John Money, PhD, was falling into disrepute for his controversial opinions on issues like incest and chemical castration of inmates. Money had been gathering data on the successes of gender-affirming surgery, but had lost funding and support. Meanwhile, in the study by Meyer, vaginoplasty cases were found to be not "successful" in the long term.

However, according to Magrath, these cases were outdated: "By 1979, Meyer and Reter's results did not reflect the present state of the art, such as Georges Burou's penile skin flap inversion vaginoplasty and other techniques that yielded more encouraging results with fewer complications."

Righting Wrongs?

While the Johns Hopkins Center for Transgender Health opened in July 2017, "medicine's history of transphobia looms prominently. Today at Johns Hopkins, 1 of the 2 services in the Department of Plastic Surgery is named after Hoopes," Magrath wrote.

Magrath "presents a reminder that transphobia and reactionary politics continue to negatively affect access to this medically necessary care that has been shown repeatedly to result in improved mental health outcomes, psychosocial functioning, and quality of life for TGD persons," noted Keuroghlian and Radix in their editorial.

"Clinicians must recognize the potential of scientific evidence to be weaponized to serve these broader political agendas. Access to gender affirmation is a matter of medical justice that all physicians must work to protect," Magrath concluded.

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