The dictionary defines gender as the state of being male or female (typically used with reference to social and cultural differences rather than biological ones) [1] and dysphoria as the state of unease or generalized dissatisfaction with life, the opposite of euphoria [2]. The term dysphoria is from the Greek word dysphoros meaning “hard to bear” [3].

Below are two medical definitions of gender dysphoria, both from the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC), the first from the earliest (1979) [4] version, Standards of Care, The hormonal and surgical sex reassignment of gender dysphoric persons, and the second from the current and seventh version (2011) [5] Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. Both documents and their intervening versions are written and distributed by WPATH, formerly known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA).

Gender dysphoria herein refers to that psychological state whereby a person demonstrates dissatisfaction with their sex of birth and their sex role, as socially defined, which applies to that sex, and who requests hormonal and surgical sex reassignment. Gender dysphoria, herein, does not refer to cases of infant sex reassignment or re-announcement nor does it refer to those persons who, although dissatisfied with their genetically and socially defined sex status (i.e., transvestites and transgenderists), usually do not request sex reassignment. Gender dysphoria, therefore, is the primary working diagnosis applied to any and all persons requesting surgical and hormonal sex reassignment [6].

Gender dysphoria – Distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) [7].

These two definitions, separated by 32 years between the first and the seventh guidelines, reflect the overarching change in the evolution of the professional approach to gender dysphoria.

Using the SOC as a mirror of the evolution, the original professional approach was a medicalized one, and these guidelines of care described the medical management of gender dysphoria and presumed a full transition from one sex to another (the sex-change model).

The title, as noted above, of the 1st SOC was “Standards of Care, The hormonal and surgical sex reassignment of gender dysphoric persons.”

In the most recent SOC, the medical part of the definition (about requesting sex reassignment) has been intentionally omitted. The current professional approach has been to broaden the focus of transgender health [8], with an emphasis on health and not only on treatment. Individuals with gender dysphoria requesting medical care receive individualized health care, which may or may not include hormonal and/or sex reassignment. These SOC include other aspects of health care, for example, reproductive health, voice and communication therapy, lifelong preventive and primary care, and care in institutional environments [9]. Psychological care has been included from the beginning.

Thus, the title of the 7th SOC is “The Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People,” unlike the early ones that specifically mention sex reassignment.

Another major change from the original SOC, consistent with the above change from treatment to health, is a shift in gender paradigms.

Initially, a binary system of gender (man, woman, boy, girl) was the predominant paradigm. Now, the view is that gender falls on a spectrum and multiple gender identities and expressions are possible.

In addition, although not clear from these definitions, professional consensus has moved away from seeing gender dysphoria as a disorder and now sees it as part of an overall pattern of gender diversity [10].

The approach for providers in providing health care more broadly has, as its basis, an underlying emphasis and recognition of human rights. Health care is a human right. And trans rights are part of human rights.

The evolution of the name and approach is due to an interplay of several factors such as advancing knowledge and better clinical treatments, the aforementioned changing gender paradigms, input and participation from trans people themselves including human rights and the right to self-define, the rise of the Internet, more global participation, and evolving shifts in how transgender people are seen by the culture. Expansion of knowledge beyond Western approaches is also part of the evolution. These changes have accelerated in recent years and are exponential rather than linear.

Other names used frequently in the literature include “gender identity disorder [11], the formal diagnosis set forth by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Rev. (DSM IV-TR) (American Psychiatric Association 1987) which is characterized by a strong and persistent cross-gender identification and a persistent discomfort with one’s sex or sense of inappropriateness in the gender role of that sex, causing clinically significant distress or impairment in social, occupational, or other important areas of functioning)”, “transsexualism (transsexual: an adjective (often applied by the medical profession) to describe individuals who seek to change or who have changed their primary and/or secondary sex characteristics through feminizing or masculinizing medical interventions (hormones and/or surgery) typically accompanied by a permanent change in gender role) [12]”, and “transgender (an adjective to describe a diverse group of individuals who cross or transcend culturally defined categories of gender). The gender identity of transgender people differs to varying degrees from the sex they were assigned at birth [12]”.

Although gender dysphoria, an essentially neutral label, is the term most commonly used in the current medical literature, that neutrality was not always so. Until recently, the value-laden gender identity disorder, which by definition implied a “disordered condition,” was the most commonly used term. Although the name gender dysphoria has come full circle, approaches to care have evolved.

These names cannot be separated from the evolution of professional understanding.

WPATH (formerly HBIGDA) writes and disseminates the SOC.

It is the oldest and only international multidisciplinary professional organization devoted solely to the health of trans people with the mission to promote evidence-based care, education, research, advocacy, public policy, and respect in transsexual and transgender health.

Hence, the organization is in a good position to publish guidelines that reflect the state of the art and science and evolution of care.

The SOC document the evolution of the nomenclature and prevailing medical standards and are based on the best available science and expert professional consensus.

Revisions to the 1979 Standards of Care (1980, 1981, 1990, 1998, 2001, 2011) have occurred concurrent with the advancement of knowledge.

Other classification systems naming this phenomenon are the Diagnostic and Statistical Manual of Mental Disorders (DSM) put out by the American Psychiatric Association (APA) and the International Classifications of Diseases (ICD) put out by the World Health organization (WHO). These manuals have also evolved, often along parallel lines to the SOC. Although the last publication of ICD, ICD-10, was in 1990 [13], ICD-11 has a planned publication in 2017. As both the DSM and ICD have contributed to and reflect evolving notions of health care, their nomenclature will also be described.

WPATH has worked with APA and the WHO during the period of writing of SOC7 (the SOC7 process) and beyond. WPATH has had formal consensus processes advising the workgroups for APA and the WHO regarding the nomenclature for both DSM 5 and ICD-11.

This chapter will not describe the terminology and health care of children.

By necessity, broad-brush strokes will be used to provide an overview of the evolution.

Information on the background and beginnings of approaches is followed by briefer descriptions of middle periods where the interplay of factors brings us to the dramatic shifts in recent years.

Some things have not changed such as the complexity of the condition, ethical concerns, the interdisciplinary nature of the field, and the need for social understanding and education.

Major changes include the growing number of people involved in the field including more transgender people themselves. The addition of transsexual, transgender, and gender-nonconforming people joining with providers in the evolution of approaches has had a major impact. Mainstream growing acceptance is also a factor.

The possibility of medical treatment for gender dysphoria entered the popular imagination in the early 1950s when Christine Jorgensen, an American GI, had a sex-change operation in 1951 in Denmark and then returned to the United States. Although not the first to have a “sex change,” Dr. Harry Benjamin, an early pioneer in the field [14], remarked that Jorgensen’s “sex conversion” and the worldwide publicity it created was perhaps the most important milestone in the history of transsexualism. Her surgeon Christian Hamburger in his 1953 report [14] urged the medical and legal professions to help the plight “of these unfortunate people for whom psychotherapy proved useless.”

The aforementioned Benjamin, a NY endocrinologist, saw many patients and wrote the first article about the condition in 1953 [15] in the no longer existing International Journal of Sexology.

In 1966 [16], he published his magnum opus, The Transsexual Phenomenon. In it, he interpreted transsexualism as a form of psychic intersexuality, the intensity of which varies. He suggested that the condition was due to complex factors, most likely had more than one causation, and was primarily a neuroendocrine disorder. He argued that since there was no cure, it was in the best interest of both transsexuals and greater society to alleviate this intense suffering of transsexuals by sex reassignment, in selected cases [17].

Also in 1966, the Gender Clinic, championed by renowned medical psychologist Dr. John Money, opened at Johns Hopkins. The clinic lasted until 1979 when it was forced to close by pressure from psychiatry, asserting that it was treating a mental disorder by doing surgery [18].

Hopkins served as a model for gender clinics scattered throughout the United States.

The oldest and largest gender identity clinic in the world began operations in the mid 1960s and is still in operation located in Hammersmith in London and is sometimes known as Charing Cross Gender Identity Clinic [19].

Don Laub, M.D., Chief of Plastic Surgery at Stanford and also founder of Interplast, which was the forerunner of medical humanitarian ventures worldwide, founded another gender clinic, known as “the Stanford Program.” Laub led medical teams on humanitarian surgical trips to the developing world and at the same time developed new surgical techniques for sex-reassignment surgery. Eventually, he moved to private practice but was never forced to close. Laub was instrumental in the foundation of the organization that was later to become WPATH, serving as President from 1981 to 1983 [20].

Psychiatrist and lawyer Richard Green and medical psychologist John Money (eds) published a multidisciplinary volume Transsexualism and Sex Reassignment in 1969, which, along with instructions on hormonal and genital sex reassignment, included sections on social and clinical aspects of transsexualism. Topics included such as psychological aspects, somatic aspects, treatment aspects, and medicolegal aspects, are themes that continue to be major topics today.

The editors dedicated the volume to Harry Benjamin, M.D., the pioneer of transsexual research, stating: His compassion and courage in treatment of the transsexual patient opened a new frontier in the knowledge of human nature [21].

Hence, foundational themes and key points from the earliest years included the following:

Early pioneers and early conferences

Prior to the 1st SOC, a small group of interdisciplinary professionals supported by wealthy transsexual Reed Erickson via his foundation, the Erickson Educational Foundation, assembled at six conferences in Europe and the United States to discuss the new medical condition known then as either gender disorientation, transsexualism, or gender dysphoria, starting in July 1969 with the 1st International Symposium on Gender identity: Aims, Functions, Clinical Problems of a Gender Identity Unit, London. These international symposia continue to this day, with the 23rd just held in February 2014 in Bangkok, Thailand. The next will be held in Amsterdam, the Netherlands, in 2016.

The people involved were pioneers and highly respected in their fields.

Some of the concerns of the early conferences are equally compelling today.

In the opening address of the first conference in 1969, Professor C. J. Dewhurst from Queen Charlotte’s Hospital, London, states, “I actually regard this to be one of the most difficult conditions I have ever come across in clinical medicine. If we consider the condition as an anomaly that would be cured by getting the patient to accept their true anatomic sex, can we say that is ever possible?” To paraphrase Dr. Dewhurst, “What do we know of its origin? Under what circumstances does it arise? If we medically intervene, what are criteria and at what age? What is their legal sex? Can they marry?” [22].

The cover of the brochure states the following: In addition to the medical and research aspects of the problem, there is urgent need for greater academic and professional understanding and for education, the latter of which could be said to be the most pressing need today.

At the 1971 2nd International Gender Identity Symposium in Denmark, there was a recognition that this is an interdisciplinary, complex condition and area of human rights. The brochure stated that the field calls attention on the problem of gender identity and “gender disorientation, not only as a psychiatric entity but also as an area of specialized medical study and treatment and social understanding” [23].

The 1973 3rd Symposium on Gender Identity in Dubrovnik included families along with surgery and etiology as topics of discussion [24].

The 4th conference on Gender Identity in Palo Alto in 1975 was the first to use the Harry Benjamin name in the title. It also focused on the interdisciplinary exchange of scientific information and how to achieve greater acceptance. In a first-person recollection, Roy Mackenzie stated that the “first step was to make it professionally respectable to even study such material” [25].

At the 1977 5th International Gender Dysphoria Symposium in Norfolk, VA, a founding committee for an interdisciplinary international organization named after Harry Benjamin, the Harry Benjamin International Gender Dysphoria Association (HBIGDA), was founded and charged with developing Standards of Care guidelines based on knowledge and ethics at that time. Paul Walker, Ph.D., a protégé of John Money, was named as chair [26].

This period marked the beginning of gender clinics, the first surgeries, and the beginning of psychopathologization as a sexual deviation in the nomenclature. The paradigm was clearly binary.

The two strands of literature and approaches still continue today, but one (reparative) is now considered unethical and is not part of mainstream care. The early specialized conferences draw surprising parallels to today.